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WOOD'S    MEDICAL   HAND   ATLASES. 


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offered  to  the  profession,  see  inside  of  back  cover. 


>u4r 


ATLAS 


OF 


TRAUMATIC 

FRACTURES  AND  LUXATIONS 


WITH  A  BRIEF  TREATISE 


BY 

H.  HELFERICH,  M.D., 

PROFESSOR  AT  THE  UNIVERSITY  OF  GREIFSWALD. 


WITH    ONE    HUNDRED    AND    SIXTY-SIX    ILLUSTRA- 
TIONS AFTER  ORIGINAL    DRAWINGS 
BY  DR.   JOS.  TRUMPP. 


NEW  YORK: 

WILLIAM  WOOD  AND   COMPANY. 

1896. 


PREFACE. 


This  Atlas  and  Treatise  are  intended  to  aid  stu- 
dents entering  upon  that  important  field  of  surgery 
which  embraces  fractures  and  luxations,  and  to  be  a 
useful  book  of  reference  to  physicians  in  their  prac- 
tice. I  have  endeavored  to  furnish  a  work  of  prac- 
tical utility,  and  at  the  same  time  to  facilitate  the 
comprehension  of  the  questions  arising,  especially  as 
regards  anatomical  details. 

The  first  instigation  came  from  the  publishers, 
whose  proposition  I  gladly  accepted.  On  the  one 
hand,  I  was  pleased  to  utilize  in  this  connection  the 
specimens  and  drawings  which  I  had  accumulated 
in  the  course  of  years ;  on  the  other  hand,  it  appeared 
to  me  desirable  to  aid  the  more  general  spread  of 
useful  knowledge  in  a  department  where  much  harm 

*\$s^  can  be  done,  and  which,  at  present  in  particular,  is  of 

M^-    great  importance  to  every  practitioner  by  reason  of 

.  y     novel  social  arrangements. 

/^         I  would  lay  special  stress  upon  the  fact  that  this 

fj  book  is  by  no  means  intended  to  take  the  place  of 
studies  at  the  clinic  or  in  special  courses,  but  is  to 
form  a  supplement  to  the  demonstrations  and  expla- 

X    nations  of  the  instructor. 

With  very  few  exceptions,  the  Atlas  presents  only 
original   drawings   from   specimens,  many  of   them 

r-*  O  •,  +0  w-isi  iii 


iV  PREFACE. 

recently  prepared.  I  have  striven  to  utilize  the  si')ace 
at  my  disposal  to  the  best  advantage  and  to  furnish 
illustrations  both  theoretically  and  practically  charac- 
teristic and  instructive.  In  these  endeavors  I  have 
been  well  seconded  by  Dr.  J.  Trumpp,  who  undertook 
the  artistic  part  of  the  work  and  made  the  original 
drawings. 

Many  specimens  illustrating  important  injuries 
were  artificially  produced,  and  prepared  in  the  man- 
ner I  have  been  accustomed  to  for  years  in  connec- 
tion with  the  operative  course  on  the  cadaver.  Some 
figures  show  specimens  observed  by  me  while  as- 
sistant to  Dr.  Thiersch  at  the  Leipsic,  Munich,  and 
Greifswald  clinics;  others  were  kindl}"  placed  at  my 
disposal  by  Professor  Bollinger  and  by  my  colleague, 
Professor  Grawitz,  from  the  pathologico-anatomical 
collections  in  Munich  and  Greifswald. 

As  the  explanations  printed  opposite  the  plates  did 
not  appear  to  me  sufficient,  the  Treatise  was  pre- 
pared, which  is  printed  in  separate  divisions  to  ac- 
company each  section  of  the  Atlas.  The  lesions  of 
frequent  occurrence  and  of  practical  importance  are 
treated  in  detail ;  the  rare  injuries  are  explained  very 
briefly. 

It  is  hoped  that  the  book  will  be  of  some  use. 

H.  Helferich,  M.D. 
Greifswald,  October,  1894. 


CONTENTS. 


I.  Fractures.      General   Remarks    on    their  Production, 

Symptoms     (Displacement),     and    Treatment. 
Plates  1-6. 
General  Remarks  on  Fractures,     . 

S3anptoms  of  a  Recent  Fracture,    . 
Examination  of  the  Fracture, 
Course  and  Reparative  Process  of  Fractures, 
Untoward  Accidents  in  Fractures, 
Treatment  of  Fractures, 
General  Remarks  on  Luxations  (Dislocations), 

II.  Fractures  of  the  Skull.     Plates  7-13. 

Fractures  of  the  Skull,    .... 

III.  Fractures  and  Luxations  of  the  Lower  Maxilla,  the 

Thorax,  and  the  Spinal  Column.  Plates  13-18 
Fractures  of  the  Bones  of  the  Face, 
Luxations  of  the  Lower  Maxilla,  . 
Fractures  of  the  Spinal  Column,  . 
Luxations  of  the  Spinal  Column,  . 
Fractures  of  the  Ribs,  . 
Fractures  of  the  Sternum, 

IV.  Fractures  and   Luxations  of  the  Upper  Extremity 

Plates  19-44. 
Fractures  and  Luxations  of  the  Upper  Extremity, 

1.  Fractures  of  the  Clavicle, 
Luxations  of  the  Clavicle, 

2.  Scapula 

3.  Shoulder-Joint, 

a.  Forward  Luxations  of  the  Humerus, 

(1)   Extension    with  Arm   Slightly    Ab 
ducted, 


1 
5 

8 
9 

13 
16 
23 

29 


37 
39 
40 

44 
45 

47 


49 
49 
53 
55 
56 
57 

61 


VI  CONTENTS. 

PAGE 

(2)  Kocher's  Method  of  Rotation,    .  01 

h.   Downward  Luxations  of  the  Humerus.  64 

c.   Backward  Luxations  of  the  Humerii?.  04 

4.   Ann,            ••.....  64 

A.  Fractures  at  the  Upper  End,      .  .04 

a.  Fracture  of  the  Anatomical  Neck,        .  04 

b.  Fracture  at  the  Surgical  Neck,     .         .  05 

c.  Fracture  of  the  Tuberosity,           .  07 

d.  Traumatic  Separation  of  the  Epiphy- 
sis,             07 

B.  Fracturesof  the  Diaphysis  of  the  Humerus,  09 

C.  Fractures  at  the  Lower  End  of  the  Hu- 

merus,      70 

a.  Supracondylar  and  T-Fractures,  72 
h.  Fractures  of  the  Condyles,  .  .  .73 
c.   Oblique    Fractures    of    the   Articular 

End, 73 

n.   El  bow -Joint, 74 

a.  Posterior  Luxation  of  the  Forearm,     .  75 

b.  Lateral  Luxation  of  the  Forearm,  77 

c.  Anterior  Luxation  of  the  Forearm,       .  79 

d.  Divergent  Luxation  of  the  Forearm,    .  79 

e.  Isolated  Luxation  of  the  Ulna,  ,  .  79 
/.   Isolated  Luxation  of  the  Radius,           .  80 

0.   Forearm,     ........  82 

A.  Fracture  of  both  Forearm  Bones,       .  82 

B.  Fractures  of  the  Ulna,         .  .85 

a.  Fracture  of  tlie  Olecranon,  .  .85 

b.  Fracture  of  the  Coronoid  Proce.ss,  87 

c.  Fracture   of    the   Ulna   in   the  Upper 
Third,  with  Luxation  of  the  Capitulum 

of  the  Radius 88 

d.  Fracture  of  the  Diaphysis  of  the  Ulna,  89 

e.  Fracture  of  the  Styloid  Process  of  the 
Ulna 90 

C.  Fractures  of  the  Radius,     ....  90 

(I.  Fracture  of  the  Capitulum  of  the  Ra- 
dius   90 


CONTENTS. 


Vll 


h.  Fracture  of  the  Diaphysis  of  the  Ra- 
dius,         91 

c.  Fracture  of  the  Lower  Diaphysis  of  the 
Radius,   .......     92 

D.  Luxation  in  the  Lower  Radio- Ulnar  Joint,     97 

7.  Wrist-Joint, 98 

8.  Hand  and  Fingers, 98 

A.  Fractures, 98 

B.  Luxations, 99 

V.   Fractures  and   Luxations  of    the  Lower  Extremity. 

Plates  45-64. 

1.  Pelvis, 103 

2.  Hip-Joint, 106 

A.  Backward  Luxation  (L.  postica  s.   retro- 
cotyloidea), 107 

B.  Forward  Luxation  (L.  antica  s.  prsecoty- 
loidea), Ill 

C.  Rare  Luxations  at  the  Hip-Joint,       .         .   113 

3.  Thigh, 113 

A.  Fractures  at  the  Upper  End  of  the  Femur,   113 

a.  Fracture  of  the  Neck  of  the  Femur,     .   113 
h.  Isolated  Fracture  of    tlie  Great  Tro- 
chanter,   118 

B.  Fractures  of  the  Diaphysis  of  the  Femur,     119 

C.  Fractures  at  the  Lower  End  of  the  Femur,    122 

4.  Knee-Joint, 123 

A.  Luxations  at  the  Knee-Joint,     .         .         .   123 

B.  Luxations  of  the  Patella,    .         .         .         .124 

C.  Fractures  of  the  Patella,     .         .         .         .126 

5.  Leg, 129 

A.  Fracture  of  Both  Bones  in  the  Region  of 
the  Diaphysis, 129 

B.  Isolated  Fracture  of  the  Tibia,   .         .         .131 

a.  Fracture  of  the  Tibia  at  its  Upper  End,   131 

b.  Traumatic  Separation  of  the  Epiphysis,  132 

c.  Separation   of    tlie   Tuberosity   of  the 
Tibia, 132 

d.  Fracture  of  the  Shaft  of  the  Tibia,       .   133 


Vlll  CONTENTS. 

PAGE 

C.  Isolated  Fracture  of  the  Fibula,  .        .  133 

D,  Fractures  at  the  Lower  End  of  Both  Bones,  134 

a.  Typical  Fracture  of  the  Ankle,    .         .   134 

b.  Other  Fractures  of  the  Ankle,       .         .   138 

c.  Separation  of  the  Epiphyses  at  the 
Lower  End  of  the  Leg  Bones,         .         .138 

d.  Supramalleolar  Fracture  of  Both  Leg 
Bones 138 

6.  Ankle-Joint, 139 

a.  Luxations  at  the  Astragalo- Crural 
Joint, 139 

h.  Luxations  at  the  Astragalo-Tarsal 
Joint,      .......   139 

c.  Isolated  Luxation  of  the  Astragalus,    .   140 

7.  Foot,  .         .  140 

A.  Fi-acture  of  the  Tarsal  Bones,    .         .         .140 

a.  Fracture  of  the  Astragalus,           .         .  140 

b.  Fracture  of  the  Calcaneus,   .         .         .  141 

c.  Fracture  of  the  Remaining  Bones,        .  141 

B.  Luxations, 142 

a.  Luxation  of  the  Tarsal  Bones,      .         .142 

b.  Luxation  of  the  Metatarsal  Bones,        .   142 

c.  Luxation  of  the  Toes,    ....   142 


LIST  OF  ILLUSTRATIONS. 


Plate  1. — Infractions  (Greenstick  Fractures). 

Fig.  1  a  and  h.  Tibia  and  fibula  of  the  left  leg  with  in- 
fractions. 
Fig.  2.  Artificial  infraction  of  the  fibula. 
Plate  2. — Fractures  by  Torsion. 

Fig.  1.  Fracture  by  torsion  of  the  shaft  of  the  femur  in  its 

upper  half. 
Fig.  2.  Artificial  fracture  by  torsion  of  the  femur. 
Plate  3. — Forms  of  Fracture  by  Traction  and  Compression. 
Comminution  by  Machinery. 
Fig.  1.  Pronounced  fracture  by  traction.     The  carpal  ex- 
tremity of  the  radius  and  ulna  of  an  adult. 
Fig.  2,  Upper  end  of  the  humerus  with  united  fracture  by 

compression. 
Fig.  3.  Comminution  of  the  bones  of  the  forearm  at  the 
carpal  extremity  by  powerful  machinery. 
Plate  4. — Gunshot  Fractures, 

Fig.  1.  Femur  with  extensive  splintered  fracture  caused 
by  a  gunshot  wound  by  the  German  army  rifle,  model 
No,  88,  at  a  distance  of  600  metres. 
Fig,  2  a  and  5,  Gunshot  perforation  of  the  humerus  at  its 
upper  end,  produced  by  the  army  rifle,  model  No.  88, 
at  a  distance  of  1,500  metres. 
Plate  5. — Displacement  of  the  Fragments. 

Figs.  1  and  2.  United  fracture  of  the  femur  with  displace- 
ment. 
Plate  6. — Reparative    Process    in  Fractures,    Formation    of 
Callus. 
Fig.  1.  Section  of  a  humerus  with  multiple  fractures  and 

extensive  callus  formation  on  the  shaft. 
Fig.  2.  Section  of  a  humerus  with  angular  union. 

ix 


X  LIST   OF    ILLUSTRATIONS. 

Fig.  3.   Fracture  of  rib  without  displacement,  with  abun- 
dant external  callus. 
Fig.  4.   Fracture  of  the  tibia  united  with  displacement. 
Plate  7.— Gunshot  Wound  of  the  Skull  at  200  Metres. 
Fig.  1.   Wound  of  entrance. 
Fig.  2.  Wound  of  exit. 
Plate  8. — Fractures  of  the  Vault  of  the  Cranium. 

Fig.  1.   Gunshot  wound,   from  without  and  from  within 

(artificial) . 
Fig.  2.   Slight  gunshot  injury  (artificial). 
Fig.  3.   Old  fracture  of  the  vault  of  the  cranium,  united 
with  depression  of  the  fragments  and  thickening  of 
the  bone  at  the  point  of  fracture. 
Fig.  4.  Vault   of   the   cranium   with   fissure    in  the  left 
parietal  bone  and  diastasis  of  the  right  half  of  the 
lambdoidal  suture. 
Plate  9. —Fracture  of  the  Skull  with  Rupture  of  the  Menin- 
geal Arter}'. 
Fig.  1.  View  of  the  line  of  fracture. 
Fig.  2.  View  of  the  site  of  the  effusion  of  blood. 
Plate  10.— Fracture  by  Compression  of  the  Base  of  the  Skull. 
Fig.  1.  Transverse  fracture  of  the  base  of  the  skull. 
Fig.  2.  Longitudinal  fracture  by  compression  of  the  base 
of  the  skull. 
Plate  11.— Fracture  of  the  Base  of  the  Skull  by  the  Ix)wer 
Maxilla  and  the  Vertebra. 
Fig.  1.  Sagittal  section  through  the  base  of  the  skull  and 

the  left  maxillary  articulation  (normal). 
Fig.  2.  Fracture  of  tlie  base  of  the  skull  by  the  pressure  of 
the  on-crowding  spinal  colunm. 
Plate  12.— Fracture  of  the  Base  of  the  Skull  by  Injury  in  the 
Nasal  Region. 
Figs.  1  and  2.  Section  and  anterior  view  of  a  skull  in 
which  a  fracture  of  the  base  of  the  skull  has  resulted 
from  pressure  upon  the  region  of  the  nose  and  upper 
maxilla. 
Plate  13.— Forward  Luxation  of  the  Lower  Maxilla. 

Fig.  1.  Bilateral  luxation  of  the  lower  maxilla  artificially 
produced  on  the  cadaver  and  dis.sected. 


LIST   OP    ILLUSTRATIONS.  XI 

Figs.  2  and  3.  Articulation  of  the  lower  maxilla  in  the 
normal  state. 
Plate  14.  Fractures  of  the  Lower  Maxilla. 

Fig.  1.   Recent  fracture  in  the  body  of  the  lower  maxilla. 
Fig.  2  a  and  h.  Fracture  of  the  articular  process  of  tlie 

lower  maxilla. 
Fig.  3.  Oblique  fracture  through  the  body  of  the  lower 

maxilla  and  both  articular  processes. 
Figs.  4  and  4  a.  Hammond  s  wire  splint  for  fractures  of 
the  lower  maxilla. 
Plate  15. — Fractures  of  the  Ribs  and  the  Sternum. 

Fig.  1.  Four  ribs  showing  old  united  fractures  on  three  of 

them. 
Fig.  2.   Fracture  of  the  sternum. 

Fig.  3.  Diastasis  between    manubrium  and  body  of  the 
sternum  united  with  displacement. 
Plate  16. — Luxation  of  the  Cervical  Vertebrae. 

Fig.  1  a  and  6.   Unilateral  luxation  of  the  cervical  ver- 
tebrae. 
Fig.  2  a  and  h.  Bilateral  luxation  (by  flexion)  of  the  cer- 
vical  vertebrae. 
Plate  17. —Fracture  of  the  Cervical  Spine. 

Fracture  of  the  cervical  spine  involving  the  sixth  and 
seventh  vertebrae. 
Plate  18. — Fractures  of  the  Vertebrae.     Traumatic  Kyphosis. 
Fig.  1.  Fracture  of  the  fifth  cervical  vertebra. 
Fig.  2.  Fracture  of  a  spinous  process. 
Fig.  3.  Angular  kyphosis  by  fracture  of  vertebrae. 
Fig.  4.  Plaster  jacket  in  the  same  injury. 
Plate  19. — Subcoracoid  Luxation  of  the  Humerus,  Exterior 

View. 
Plate  20.  — The  Same  after  Exposure  of  the  Muscles. 
Plate  21. — The   Same  after  Exposure  of  the  Head  of  the 

Humerus. 
Plate  22. — The  Same,  Reduction. 
Fig.  1.   Adduction  of  the  arm. 
Fig.  2,   Outward  rotation  of  the  arm. 
Fig.  3.   Forward  elevation  of  the  arm. 
Fig.  4.  Inward  rotation  of  the  arm. 


xii  LIST   OF   ILLUSTRATIONS. 

Plate  23. — Old  Subcoracoid  Luxation;   Formation  of  anew 
Socket  on  the  Scapula  and  Abrasion  of  the  Head  of 
the  Humerus. 
Fig.  1.  Humerus  and  scapula  in  luxation,  anterior  view. 
Fig.  2.  The  same  bones  after  removal  and  rotation  of  the 
humerus  180^. 
Plate  24.  — Fractures  of  the  Scapula. 

Fig.  1.  Fracture  of  the  neck  of  the  scapula. 
Fig.  2.  The  same,  with  two  lines  of  fracture. 
Fig.  3.  Fractures  of  the  scapula  united  by  callus. 
Plate  25. — Luxations  of  the  Clavicle. 

Fig.  1.  Upward  luxation  of  the  acromial  end  of  the  clav- 
icle. 
Fig.  2.  Position  of  the  acromion  in  the  same  injury. 
Fig.  3.   Forward  luxation  of  the  sternal  end  of  the  clavicle. 
Plate  26. — Fracture  of  the  Clavicle,  with  Typical  Displace- 
ment of  the  Fragments  and  Typically  Altered  Position 
of  the  Arm. 
Plate  27. — Traumatic  Separation  of   the   Epiphysis  at  the 
Upper  End  of  the  Humerus. 
Fig.  1.  The  actual  injury. 

Fig.  2.  Consecutivedisturbancesof  growth  in  consequence 
of  the  injury. 
Plate  28. — Fractures  at  the  Upper  End  of  the  Humerus. 

Fig.  1.  Course  of  the  epiphyseal  line  on  the  section  of  the 

normal  bone. 
Fig.  2.  Separation  of  the  epiphysis  at  the  upper  end  of  the 

humerus,  posterolateral  view. 
Fig.  3.  Lines  of  fracture  drawn  in  the  anatomical  and 

the  surgical  neck  of  the  humerus. 
Fig.  4.   Old  fracture  of  the  upper  part  of  the  shaft  of  the 
humerus  united  with  marked  displacement. 
Plate  29.— Fractures  in  the  Middle  of  the  Humerus. 

Fig.  1.  Anatomical  preparation  to  show  the  position  of 

the  radial  nerve  witli  reference  to  the  bone. 
Figs.  2  and  3.  United  fractures  of  the  shaft  of  the  hume- 
rus with  some  dis])lacement  of  the  fragments. 
Plate  30. —Fractures  at  tlie  Lower  End  of  the  Humerus. 

Fig.  1  a  and  h.   Partial  separation  of  the  lower  epiphysis 
of  the  humerus. 


LIST   OF   ILLUSTRATIONS.  Xlll 

Fig.  3.  Longitudinal  fracture  of  the  humerus  extending 

into  the  elbow-joint. 
Fig.  3.  Separation  of  the  erainentia  capitata  and  the  ex- 
ternal condyle. 
Fig.  4.  Typical  transverse  fracture  of  the  humerus. 
Plate  31. — Fractures  at  the  Lower  End  of  the  Humerus  and 
at  the  Capitulura  of  the  Radius. 
Figs.  1  and  2  show  the  epiphyseal  line  at  the  lower  end  of 

the  humerus.     Bone  preparations. 
Fig.  3.  Fracture  at  the  lower  end  of  the  humerus  above 

the  condyles,  with  typical  displacement. 
Fig.  4  a  and  b.  Old,  united  fracture  of  the  capitulum  of 
the  radius. 
Plate  32. — Deformity  of  the  Arm  after  Articular  Fracture  at 
the  Lower  End  of  the  Humerus. 
Figs.  1  and  2,   Old  oblique  fracture  at  the  lower  end  of  the 
humerus,  with  formation  of  a  cubitus  valgus  (bone 
preparation) . 
Fig.  2,  The  same  condition  during  life. 
Plate  33. — Outward  Luxation  of  the  Forearm,    with  Separa- 
tion of  the  Internal  Condyle. 
Plate  34. — Backward  Luxation  of  the  Forearm. 
Plate  35.— Reduction  of  Posterior  Luxation  of  the  Forearm 

by  Hyperextension  and  Traction. 
Plate  36. — Isolated  Luxation  of  the  Capitulum  of  the  Radius 
in  Fracture  of  the  Ulna  in  the  Upper  Third,  with 
Marked  Displacement  of  the  Fragments. 
Fig.  1.  The  more  minute  anatomical  details  in  an  artificial 
preparation. 
Plate  37. — Fracture  of  the  Olecranon  and  the  Coronoid  Pro- 
cess. 
Fig.  1.  Fracture  of  the  olecranon. 

Fig.  2.  Old  bone  preparation  of  a  fracture  of  the  olecranon. 
Fig.  3.  Separation  of  the  coronoid  process. 
Plate  38.  — Fractures  in  the  Middle  of  the  Forearm. 

Fig.  1.  Unfavorable  position  of  the  fragments  in  fracture 

of  the  forearm. 
Fig.  2.  Similar  unfavorable  angular  position  ;  the  radius  • 
in  a  state  of  bony  union. 


XIV  LIST   OF    ILLUSTRATIONS. 

Fig.  3.   Nearthrosis  between  radius  and  ulna  at  the  point 

of  fracture. 
Plate  39. — Fracture  of  the  Radius.     Lower  Epiphyseal  Line 

of  the  Forearm  Bones. 
Fig.  1.  Isolated  fracture  of  the  radius  above  its  middle 

and  the  effect  of  the  biceps  on  the  position  of  the 

upper  fragment. 
Fig.  2.  Epiphyseal  lines  at  the  lower  end  of  the  radius  and 

ulna,  after  a  dry  preparation. 
Plate  40. — Typical  Fracture  of  the  Lower  Epiphysis  of  the 

Radius. 
Fig.  1  a.  Normal  forearm. 

Fig.  1  h.  Forearm  in  typical  fracture  of  the  radius. 
Fig,  2.   Fracture  of  the  radius,  separation  of  a  portion  of 

the  articular  surface. 
Fig.  3. — Transverse  fracture  of  both  forearm  bones. 
Plate  41. — Typical  Fracture  of  the  Lower  Epiphysis  of  the 

Radius. 
Fig.  1.  Typical  fracture  of  the  lower  epiphysis  of  the 

radius,  lateral  view. 
Fig.  2. — Longitudinal  section  through  the  forearm  in  this 

fracture. 
Plate  42. — Replacement  and  Dressing  of  the  Typical  Fracture 

of  the  Radius. 
Fig.  1.  Replacement  of  the  typical  epiphyseal  fracture  of 

the  radius. 
Fig.  2.  Application   of  a  Beely's  plaster-of -Paris  splint 

after  replacement  is  effected. 
Fig,  3. — Illustration  of  the  dressing  devised  by  Professor 

Roser, 
Plate  43.— Typical  Luxation  of  the  Thumb. 
Plate  44. — Incorrect  and  Correct  Mode 'of  Reduction  in  the 

Typical  Luxation  of  the  Thumb. 
Fig.  1,  Incorrect  mode  of  reduction  in  the  typical  luxa- 
tion of  the  thumb. 
Fig.  2.  Correct  mode  of  reduction  in  the  same  injury. 
Plate  45. — Fractures  of  the  Pelvis.     Bertini's  Ligament. 

Fig.  1.   Lines  of  fracture  in  the  anterior  circumference  of 

the  pelvis. 


LIST   OF   ILLUSTRATIONS.  XV 

Fig.  2,  Pelvic  fracture  through  the  acetabulum  in  a  boy 

aged  14. 
Fig.  3.   Ileo-femoral  or  Bertini's  ligament. 
Plate  46. — Luxation  of  the  Femur. 

Fig.  1.   Backward  luxation  of  the  femur. 
Fig.  2.  Forward  luxation  of  the  femur. 
Plate  47.  — Backward  Luxation  of  the  Femur,   Anatomical 

Preparation. 
Pla-TE  48.  — Forward   Luxation    of    the    Femur,    Anatomical 

Preparation. 
Plate  49. — Extra  capsular  Fractures  of  the  Neck  of  the  Femur. 
Fig.  1  a  and  b.  Extracapsular  fracture  of  the  neck  of  the 
femur,  with  impaction  of  the  fragment  (bone  prepa- 
ration) . 
Fig.  2  a  and  b.  United  extracapsular  fracture  of  the  neck 
of  the  femur. 
Plate  50.  — Intracapsular  Fractures  of  the  Neck  of  the  Femur. 
Plate  51.— Typical  Displacement  in  Fracture  of  the  Shaft  of 
the  Femur. 
Fig.  1.  Badly  united  fracture  of  the  femur. 
Fig.  2.  Action  of  the  muscles  upon  the  upper  fragment  of 
the  femur. 
Plate  52. — Typical  Displacement  of  the  Fragments  in  Supra- 
condylar Fracture  of  the  Femur. 
Plate  53. — Different  Fractures  of  the  Femur. 

Fig.  1.  Very  acute-angled  oblique  fracture  in  the  upper 

half  of  the  femur. 
Fig.  2.   Oblique  fracture  below  the  middle  of  the  femur. 
Fig.  3.  Old  fracture  of  the  femur,   united  with  marked 

displacement. 
Fig.  4.  Oblique  fracture  through  the  lower  articular  end 
of  the  femur. 
Plate  54.  —Vertical  Extension  in  Fractures  of  the  Femur  in 

Children. 
Plate  55.  — Fracture  of  the  Patella. 

Fig.  1.  Isolated  fracture  of  the  patella. 
Fig.  2.  The  ligamentous,  tense  tissue  adjoining  the  patella 
on  both  sides  is  severed  with  the  latter. 
Plate  56.— Fracture  and  Luxation  of  the  Patella. 


XYl  LIST   OF    ILLUSTRATIONS. 

Fig.  1.  Old  fracture  of   the  patella,    united  by  a  broad 

ligamentous  mass. 
Fig.  2.   Fragments  united  by  a  short,  broad  ligamentous 

mass. 
Fig.  3,  Fragments  united  by  a  very  long,  thin  ligament- 
ous mass. 
Fig.  4.   Outward  luxation  of  the  left  patella. 
Plate  57.  — Fractures  in  and  about  the  Knee- Joint. 
Fig.  1.   Normal  course  of  the  epiphyseal  lines. 
Fig.  2.   United  stellar  fracture  of  the  patella. 
Fig.  3  a  and  h.  Fracture  by  compression  of  the  tibia  at 
its  upper  end. 
Plate  58. — Fractures  of  the  Leg  Bones  United  with  Deform- 
ity. 
Figs.  1  and  3.  Typical  deformities  which  must  be  abso- 
lutely avoided. 
Plate  59. — Figs.  1  and  3.  Fracture  of  the  tibia  with  luxation 

of  the  capitulum  of  the  fibula. 
Plate  60. — Fractures  of  the  Leg  Bones. 

Fig.  1.  Fracture  of  the  Leg  Bones  United  with  Marked 

Displacement  of  the  Fragments. 
Fig.  3.   Fracture  of  the  leg  bones  united  with  slight  dis- 
placement of  the  fragments. 
Fig.  3.  Supramalleolar  fracture  of  both  leg  bones  united 

with  marked  displacement. 
Fig.  4.    Recent  fracture  by  torsion  at  the  lower  end  of 
the  tibia. 
Plate  61.— Typical  Malleolar  Fracture. 
Plate  62.  —Typical  IMalleolar  Fracture. 

Plate  63. — Fractures  of  the  Ankle  with  Displacement  of  the 
Fragments. 
Fig.  1.  Traumatic  pes  valgus. 

Fig.  2.   Bilateral,  typical  fracture  of  the  ankle  with  back- 
ward subluxation  of  the  foot. 
Fig.  3.   Epiphyseal  lines  of  the  tibia  and  fibula. 
Plate  64. — Luxation    of    the  Foot    in  the  Astragalo-Crural 
Articulation. 
Fig.  1.    Backwnrd  luxation. 
Fig.  3.   Forward  luxation. 


I. 
FRACTURES. 

GENERAL   REMARKS  OiX  THEIR   CAUSATION,  SYMPTOMS 
(DISPLACEMEiXTj,  AXD  TREATME^^T. 


Explanation  of   Plate    1. 

Infractions   (Green-Stick  Fractures). 

Fig.  1  a  and  b. — Tibia  and  fibula  of  the  left  leg 
of  a  boysLged  14  (William  Kohn),  who  was  severely 
injured  on  November  21st,  1889,  Idj  being  caught  be- 
tween the  cam  wheels  of  a  threshing-machine.  Both 
])ones  are  drawn  as  seen  from  the  outside.  On  the 
specimen  the  fracture  of  the  fibula  is  about  three 
fingers'  breadth  higher  than  that  of  the  tibia.  At 
the  point  of  fracture  both  bones  are  bent  backward 
so  as  to  produce  a  salient  angle  at  the  anterior  side 
and  a  depressed  angle  at  the  posterior  side.  Both 
bones  exhibit  a  marked  infraction  (green-stick  frac- 
ture) .  It  may  be  seen  plainh^  that  the  bending  causes 
first  a  separation  of  the  parts  on  the  convex  side,  and 
then  a  detachment  of  a  wedge-shaped  fragment  on 
the  concave  side;  this  wedge  is  not  fully  separated 
on  either  bone.   (Author's  collection.) 

Fig.  2. — Artificially  produced  infraction  of  the 
fibula.  The  specimen  is  taken  from  the  leg  of  a 
cadaver,  which  was  fractured  by  means  of  Rizzoli's 
osteoclast.  The  same  etfect  is  produced  by  other 
osteoclasts  or  by  breaking  a  thin  bone  over  the  edge 
of  a  table.  In  every  instance  the  base  of  the  wedge, 
whether  completely  or  incompletely  detached,  or  per- 
haps sometimes  merely  marked  by  fissures,  corre- 
sponds to  the  concave  side  of  the  bent  bone.  (Author's 
collection.) 


Fig.l' 


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Lith.Anst  v.F.Reichholci.Munchen . 


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Lith  Anst  V  F  Reichhold.Miinchen 


Explanation  of  Plate   2. 

Fractures  by  Torsion. 

Fig.  1. — Fracture  by  torsion  of  the  shaft  of  the 
femur  in  its  upper  half ;  specimen  derived  from  a 
woman  aged  88  (Anna  Kainz).  The  left  femur  is 
seen  from  in  front,  and  the  pronounced  spiral  direc- 
tion of  the  line  of  fracture  is  evident.  The  fracture 
was  caused  by  rotation  of  the  bod}^  while  the  foot  was 
fixed.  Personal  observation  at  the  surgical  policlinic 
in  Munich.   (1884,  No.  4,359.) 

Fig.  2. — Artificially  produced  fracture  by 
torsion  of  the  femur.  The  spiral  line  is  seen  ascend- 
ing from  below  upward  to  the  right ;  a  fissure  starts 
from  this  spiral,  passes  almost  vertically  downward, 
and  its  inferior  limit  again  joins  the  lowest  portion 
of  the  spiral  line.  Since  near  the  upper  end  of  the 
spiral  line  another  vertical  fissure  passes  downward 
and  meets  the  spiral  line  again  at  a  lower  point,  an 
approximately  rhombic  fragment  is  detached,  which 
is  a  characteristic  feature  in  a  large  number  of  frac- 
tures by  torsion.  The  short  sides  of  this  rhombic 
fragment  are  segments  of  the  spiral  line  of  fracture ; 
the  long  vertical  sides  comprise  about  one-fourth  of 
the  circumference  of  the  femur. 

Fracture  by  torsion  can  be  artificially  produced  on 
the  cadaver  by  thorough  fixation  of  the  limb,  vigor- 
ous torsion,  and  a  sharp  blow  with  a  hammer  at  the 
point  where  the  fracture  is  desired.  (Author's  collec- 
tion.) 


Explanation  of  Plate   3. 

Forms  of  Fracture  by  Traction  and  Compres- 
sion.    Comminution  by  Machinery. 

Fig.  1. — Pronounced  fracture  by  traction.  The 
carpal  extremity  of  the  radius  and  ulna  of  an 
adult  J  both  stj'loid  processes  are  torn  off  in  a  jagged 
line.  This  separation  is  obvioush"  the  result  of  a 
sudden  traction  transmitted  through  the  lateral  liga- 
ments, in  the  present  instance  caused  by  injury  to  the 
hand  in  a  machine.  The  separation  of  the  styloid 
process  of  the  ulna  is  incomplete.  (Personal  observa- 
tion.) 

Fig.  2. — Upper  end  of  the  humerus  with  united 
fracture  by  compression.  The  head  of  the  humerus 
and  the  upper  end  of  the  shaft  are  markedly  displaced, 
but  still  united  by  abundant  callus.  The  latter,  with 
its  velvety,  partly  porous  structure,  can  be  prettj-  well 
recognized  in  the  illustration.  The  fragment  of  the 
head  likewise  is  not  normal,  but  is  traversed  by 
fissures  at  the  anatomical  neck  and  within  the  tubercle, 
which  contribute  to  the  deformity  and  at  the  same 
time  exhibit  the  effect  of  compression.  The  upper 
end  of  the  shaft  is  displaced  forward  and  inward,  and 
also  shifted  upward.  The  fragments  are  lixed  by  a 
spongy  mass  of  callus;  the  joint  was  immovable. 
(Author's  collection.) 

Fig.  3. — Comminution  of  the  bones  of  the  f(rre- 
arm  at  their  carpal  extremity  by  powerful  ma- 
chinery. The  patient  (Harloff),  a  man  aged  50, 
was  injured  on  December  21st,  1H91,  while  tending 
an  engine;  he  stumbled,  and  his  left  arm  was  caught 
in  the  drum.  As  the  soft  parts  were  extensively  con- 
tused the  forearm  was  immediately  amputated.  The 
healing  of  the  wound  and  of  a  compound  fracture  of 
the  upper  arm  which  was  present  at  the  same  time 
was  perfect.     (Author's  collection.) 


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Explanation  of  Plate  4. 

Gunshot  Fractures. 

Fig.  1. — Femur  with  extensive  splintered  frac- 
ture caused  by  a  gunshot  wound  by  the  German 
army  rifle,  model  No.  88,  at  a  distance  of  600 
metres.  The  drawing  shows  the  posterior  surface 
of  the  femur  with  the  wound  of  exit  and  a  large 
number  of  replaced  fragments.  At  the  anterior  sur- 
face of  the  femur  is  the  somewhat  smaller  wound  of 
entrance.  Such  a  comminution  of  the  bone  with 
the  associated  injury  of  the  soft  parts  would  be  an 
indication  for  amputation.     (Author's  collection.) 

Fig.  2  a  and  b. — Gunshot  perforation  of  the  hu- 
merus at  its  upper  end,  produced  by  the  army 
rifle,  model  No.  88,  at  a  distance  of  1,500  metres. 

On  the  fresh  specimen  the  soft  parts,  periosteum, 
and  bone  showed  a  smooth  perforation.  The  bullet 
represented  at  b  had  entered  at  the  anterior  surface 
of  the  humerus,  made  the  perforation  shown,  and 
was  lodged  behind  under  the  skin  (Fig.  2  b). 

On  the  macerated  specimen  there  is  a  fissure  be- 
ginning at  the  point  of  impact,  extending  upward 
and  outward  through  the  tubercle,  and  passing  al- 
most completely  around  the  anatomical  neck.  The 
wound  of  exit  at  the  posterior  side  of  the  humerus  is 
slightly  larger  than  that  of  entrance,  but  still  of  a 
rounded  form.     (Author's  collection.) 


Explanation  of  Plate   5. 
Displacement  of  the  Fragments. 

Figs.  1  and  2  show  different  views  of  the  same 
specimen  of  a  united  fracture  of  the  femur.  It  is  a 
good  object  for  demonstrating  the  forms  of  displace- 
ment, all  of  which  are  combined  in  this  one  specimen. 

The  fragments  are : 

a.  Displaced  laterally  so  that  their  ends  do  not 
meet  but  overlap  completely,  i.e.,  dislocatio  ad 
latus. 

b.  These  laterally  shifted  fragments  are  displaced 
side  by  side  in  a  longitudinal  direction  so  that  the 
entire  bone  is  materially  shortened,  i.e.,  dislocatio 
ad  longitudinem  ciun  contractions. 

c.  The  fragments,  however,  are  not  so  juxtaposed 
that  their  longitudinal  axes  are  parallel,  but  the  axis 
of  one  fragment  is  at  an  angle  to  that  of  the  other — 
the  fragments  are  united  at  an  angle,  i.e.,  dislocatio 
ad  axin. 

d.  Finally,  during  this  multiple  displacement,  one 
of  the  fragments  has  also  rotated  on  its  longitudinal 
axis.  Fig.  1  shows  the  upper  fragment  exactly  from 
in  front;  the  lower  one  therefore  is  markedly  turned 
inward,  i.e.,  dislocatio  ad peripheriam. 


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General  Remarks  on  Fractures. 

In  the  discussion  of  fractures  we  must  distinguish 
above  all  those  due  to  an  extraneous  force  (traumatic 
fractures)  from  such  as  occur  independently  of  an 
extraneous  force  or  from  so  slight  a  cause  as  would 
not  suffice  to  break  a  healthy  bone  (spontaneous 
fractures) . 

Spontaneous  fractures  are  the  result  of  fragility  of 
the  bone,  due  as  a  rule  to  tumors  (sarcomata,  meta° 
static  carcinomata,  echinococcus  cysts,  etc.),  and  to 
inflammatory  diseases  of  the  bone  (osteomyelitic  ne- 
crosis not  supported  by  an  appropriate  box  splint, 
bone  abscess,  tuberculous  caries,  syphilis,  rickets, 
osteomalacia,  etc.).  The  following  explanations  do 
not  appl}^  to  such  spontaneous  fractures. 

The  observations  here  given  refer  to  traumatic 
fractures  of  healthy  bones. 

We  distinguish  compound  fractures  and  simple  or 
subcutaneous  fractures.  A  compound  fracture  is  one 
associated  with  an  injury  of  the  skin  and  soft  parts 
at  the  point  of  fracture.  As  a  rule  such  a  complica- 
tion exposes  the  seat  of  the  fracture  and  subjects  it  to 
the  danger  of  infection  from  without ;  even  a  slight 
lesion  of  the  skin  and  soft  parts  which  does  not  reach 
as  far  as  the  seat  of  fracture  is  included  in  the  term. 
In  these  cases  the  antiseptic  or  aseptic  treatment  of 
the  wound  must  always  be  carried  out  strictly  in  ac- 
cordance with  surgical  rules.     In  this  way  alone  are 

1 


2  FRACTURES   AND   LUXATIONS. 

we  justified  in  expecting  a  favorable  course  of  such 
open  fractures  which  in  former  times  were  fraught 
with  dangers.  In  other  respects  the  treatment  of 
these  fractures  follows  the  same  principles  applying 
to  the  simple  variety,  and  aims  at  a  firm  knitting  of 
the  broken  bone,  with  the  least  possible  displacement. 

It  is  a  matter  of  frequent  experience  that  this  task 
is  much  more  difficult  in  compound  fractures,  and 
that  often  we  have  to  be  satisfied  with  results  which 
are  not  absolutely  perfect. 

According  to  the  degree  of  separation  of  the  bone 
at  the  seat  of  the  injury  we  distinguish  complete  and 
incomplete  fractures.  The  latter  include  fissures 
which  traverse  the  bone  without  altering  its  external 
form,  and  infraction  or  green-stick  fracture,  which 
is  observed  most  frequently  on  the  bent  leg  bones  of 
rachitic  children,  but  occurs  also  in  the  tubular  bones 
of  adults  and  in  flat  bones. 

In  complete  fractures  the  lines  of  separation  may 
pass  in  very  different  directions;  hence  we  distin- 
guish transverse,  oblique,  longitudinal,  and  spiral 
fractures.  When  small  particles  are  completel}'  de- 
tached at  the  point  of  fracture,  whether  or  not  they 
are  still  connected  with  the  periosteum,  the  fracture 
is  called  comminuted ;  but  when  a  larger  portion  is 
broken  off  at  the  seat  of  the  injury  we  may  designate 
it  a  separation  of  a  fragment  or  splinter. 

It  is  a  matter  of  some  importance  whether  the  frac- 
ture is  direct  or  indirect.  This  term  is  used  to  desig- 
nate the  seat  of  the  fracture  with  reference  to  the 
force  causing  the  injury.  When  the  fracture  occurs 
at  the  point  of  injur}',  as  for  instance  in  parrying  a 
blow   with   the   forearm    (parrying  fracture  of  the 


GENERAL   REMARKS   ON   FRACTURES.  6 

ulna),  it  is  a  direct  fracture.  But  when  a  fracture 
of  the  clavicle  occurs  in  a  child  from  a  fall  on  the 
hand,  it  is  an  indirect  fracture.  Inasmuch  as  in  a 
direct  fracture  the  marks  of  the  effective  force  (con- 
tusion and  consequent  ecchj^mosis)  appear  at  the  seat 
of  the  fracture,  such  injuries  as  a  rule  are  considered 
to  be  more  serious  than  indirect  fractures. 

A  very  essential  point,  morever,  is  the  occurrence 
of  various  form  of  fracture  at  different  ages.  It  is 
obvious  that  the  middle  adult  age  furnishes  the  larg- 
est number  of  fractures,  for  at  this  period  the  heavi- 
est labor  is  performed  and  the  liability  to  the  dangers 
and  accidents  connected  with  it  is  greatest.  In  order 
to  calculate  correctly  the  statistical  proportion  the 
number  of  the  population  at  the  various  ages  must 
be  taken  into  consideration.  We  then  find  that 
fractures  are  most  frequent  between  30  and  40  years 
(15.4^),  and  that  they  are  more  frequent  in  advanced 
age  than  in  childhood;  the  minimum  is  found  in 
children  up  to  the  age  of  10  years.  The  occurrence 
of  fractures  in  advanced  age  is  in  part  the  result  of 
an  increased  fragility  due  to  a  senile  atrophy  of  the 
osseous  tissue  (diminution  of  the  organic  substance 
in  the  bone).  In  early  age  the  presence  of  the  carti- 
laginous symphysis  between  diaphyses  and  epiphyses 
plays  an  important  part ;  often  enough  there  is  not  a 
true  fracture  of  the  tubular  bones,  but  a  traumatic 
separation  of  the  epiphysis,  such  as  occurs  spontane- 
ously in  inflammatory  processes,  especially  in  acute 
osteomyelitis  and  also  in  syphilis. 

In  considering  the  mechanism  of  the  production  of 
fractures,  the  description  is  to  be  based  upon  the 
study  of  specimens  obtained  by  accident  and  those 


4  FRACTURES   AXD   LUXATIONS. 

artificially  produced  on  the  cadaver.  The  results 
thus  secured  agree  with  each  other;  most  forms  of 
fracture  can  be  artificially  produced  without  diffi- 
culty. 

Infraction  (green-stick  fracture)  results  from  flex- 
ion of  a  bone  beyond  the  limits  of  its  elasticity.  In 
the  same  way  as  a  stick  is  broken  across  the  knee 
and  parts  first  on  the  convex  side,  so  does  a  long  tubu- 
lar bone  bent  in  like  manner.  This  happens  in  vari- 
ous ways.  The  form  of  the  green-stick  fracture  is 
quite  characteristic;  see  Plate  1.  An  incomplete 
development  of  these  lines  of  fracture  produces  trans- 
verse and  oblique  fractures. 

We  might  perhaps  distinguish  a  special  form  of 
infraction  caused  by  lateral  pressure  ujDon  the  end  of 
a  bone  otherwise  fixed  ;  for  instance,  fracture  of  the 
fibula  in  the  typical  malleolar  fracture  by  pressure  of 
the  astragalus.  In  part  this  is  certainly  a  process 
of  flexion. 

Fracture  by  torsion  results  from  twisting.  This 
is  possible  when  one  end  of  the  bone  is  fixed  and  the 
rest  of  that  part  of  the  body  is  twisted.  This  pro- 
duces a  spiral  fracture  which  can  also  be  effected  arti- 
ficially; see  Plate  2.  When  the  bone  is  twisted  to 
the  right  the  resulting  spiral  turns  toward  the  right. 
Torsion  causes  many  oblique  and  longitudinal  frac- 
tures. 

Fracture  by  compression  is  due  to  a  crushing  force 
acting  on  a  bone.  This  force  may  be  exerted  in  the 
longitudinal  direction  of  a  tubular  bone,  in  which 
case  there  result  characteristic  infractions  at  the  can- 
cellous end  of  the  bone,  as  well  as  complete  fracture 
with  impaction  of  the  fragments  into  each  other  (for 


GEKERAL  REMARKS  ON"  FRACTURES.         O 

instance,  at  the  upper  end  of  the  humerus,  tibia, 
etc.,  crushing-  of  the  calcaneus  by  a  fall  upon  the 
feet.  See  Plate  3,  Fig.  2).  To  the  same  class  be- 
longs also  the  detachment  by  contusion  of  small 
marginal  portions  from  the  articular  ends. 

Fracture  by  traction  results  from  the  sudden  pull 
of  muscles  or  ligaments  in  forcible  movement  of  a 
joint  (distorsion) .  Among  characteristic  instances 
are  cases  of  fracture  of  the  patella,  olecranon,  malle- 
olus, the  lower  epiphysis  of  the  radius,  etc.  See 
Plate  3,  Fig.  1. 

Gunshot  fracture  is  due  to  a  gunshot  injury  of  a 
bone.  The  specimens  illustrated  on  Plate  4  show 
the  extensive  splintering  in  close  proximity  and  the 
characteristic  gunshot  perforation  at  a  great  distance 
of  the  object. 

A  knowledge  of  these  relations  is  also  practically 
of  great  value,  occasionally,  for  the  forensic  physi- 
cian. It  is  obvious  that  not  rarely  combinations  of 
the  various  mechanical  effects  may  be  observed  in 
the  living  patient.  Powerful  forces  (injury  by  ma- 
chinery) sometimes  produce  complete  comminution 
of  bones. 

SYMPTOMS  OF  A  RECENT  FRACTURE. 

On  inquiring  for  the  symptoms  of  a  fracture  pain 
is  mentioned  with  remarkable  frequency — the  most 
unimportant  symptom,  which  moreover  would  be 
valueless  for  differentiating  a  fracture  from  a  severe 
contusion  were  it  not  that  it  is  sometimes  possible  to 
localize  this  pain  at  a  narrowly  circumscribed  spot 
or  line  of  the  bone,  while  in  contusion  pain  on  pres- 
sure is  more  frequently  felt  over  a  larger  surface. 


6  FRACTURES   AND    LUXATIONS. 

The  characteristic  feature  of  a  fracture  is  the  soki- 
tion  of  continuity  of  the  bone.  This  and  its  mechan- 
ical sequeli©  form  the  most  important  symptoms  of  a 
fracture. 

1.  The  abnormal  mobility  is  the  chief  symptom, 
which  is  more  or  less  pronounced  and  marked  in  most 
cases.  It  is  absent  in  incomplete  fractures,  i.e.^  fis- 
sures and  infractions,  and  in  imj^acted  fractures.  In 
the  latter  variety  the  smaller  and  firmer  portion  of  a 
bone  is  wedged  into  the  cancellous  part  and  so  fixed 
mechanically  that  the  two  pieces  again  form  a  single 
bone.  This  occurs  particularly  in  fractures  of  the 
neck  of  the  femur,  though  it  is  met  with  also  at  other 
articular  ends  and  different  tubular  bones.  In  other 
cases,  as  in  fractures  of  short  bones,  the  ribs,  etc., 
abnormal  mobility  cannot  alwaj'S  be  demonstrated. 

2.  Crepitation,  the  sensation  of  friction  (possibly 
also  an  audible  friction  sound),  on  displacing  the 
broken  ends  on  each  other,  results  from  rubbing  the 
recently  fractured  surfaces  together.  Crepitation  is 
conditional  on  the  presence  of  abnormal  mobility; 
for  where  the  latter  is  absent,  where  the  fractured 
surfaces  cannot  be  displaced  on  each  other,  no  crepi- 
tation can  result.  This  symptom,  therefore,  cannot 
be  perceived  in  fissures,  infractions,  and  impacted 
fractures.  In  other  cases,  in  which  the  abnormal 
mobility  is  not  clearly  demonstrable,  some  sort  of 
crepitation  can  still  at  times  be  noticed  with  appropri- 
ate attempts  at  displacement. 

In  other  cases,  however,  the  abnormal  mobility  is 
characteristically  present,  often  even  very  markedly, 
and  still  crepitation  is  absent.  This  is  the  case  when 
the  fragments  are  so  displaced  that  they  are  no  longer 


GENERAL    REMARKS   ON    FRACTURES.  7 

in  contact  {dislocatio  ad  longitftdinem),  both  wlien 
they  are  separated  from  each  other  (diastasis),  as 
occurs,  for  instance,  with  the  fragments  of  the  pa- 
tella, and  when  they  overlap  considerably,  with  pro^ 
nounced  shortening  of  the  entire  bone. 

Crepitation  is  absent,  moreover,  when  soft  parts 
are  situated  between  the  movable  fractured  extremi- 
ties,  that  is,  when  there  is  an  interposition  of  soft 
parts,  chiefl}^  portions  of  fasciae  and  muscles.  This 
ensues  when  the  sharp  fractured  extremities  are 
widely  displaced  and  penetrate  into  the  surrounding 
soft  parts,  and  during  reduction  are  not  com.pletely 
freed.  The  interposed  tissue  in  that  case  acts  as  a 
cushion  which  prevents  the  contact  of  the  fractured 
ends. 

3.  A  third  very  important  symptom  is  deformity 
which  can  generally  be  seen  and  felt.  This  symp- 
tom is  absent  oidy  in  the  case  of  fissures  and  of  those 
rare  complete  fractures  in  which  there  is  no  displace- 
ment of  the  broken  ends.  The  deformity  is  the  result 
of  the  displacement  of  the  broken  ends.  In  order  to 
characterize  this,  it  has  long  been  customary  to  dis- 
tinguish different  forms  of  displacement  (see  Plate  5), 
namely : 

a.  Angular  displacement  of  the  fragments  (dislo- 
catio ad  axin) ; 

h.  Lateral  displacement  (dislocatio  ad  latus) ; 

c.  Longitudinal  displacement  (dislocatio  ad,  lon- 
gitudinem).  In  the  latter  case  Ave  must  distinguish 
whether  the  fragments  are  drawn  apart  (diastasis,  • 
dislocatio  ad  longitudinem  cum  distractione) ,  as 
occurs  in  fractures  of  the  olecranon  and  patella,  or 
whether  they  override  each  other  with  consequent 


8  FRACTURES   AND    LUXATIONS. 

shortening  of  the  entire  bone  (dislocatio  ad  longitu- 
dinem  cum  contractione),  as  is  frequently  observed  in 
tubular  bones.  Diastasis  occurs  only  when  the  bony 
framework  of  the  limb  is  intact,  and  merely  some 
prominences  are  subject  to  a  certain  muscular  trac- 
tion (patella,  olecranon,  trochanter,  etc.); 

d.  •i)isplacement  by  torsion  of  the  fragments  or 
fragment  around  its  longitudinal  axis  {dislocatio  ad 
perij^heriam),  slight  degrees  of  which  are  not  rarely 
seen.  It  occurs  in  a  marked  form  in  fractures  of  the 
neck  of  the  femur,  and  in  fractures  of  the  shaft  of  the 
femur  and  radius,  in  which  the  peripheral  portion 
of  the  bone  undergoes  such  displacement  when  the 
patient  is  put  to  bed. 

Further  symptoms  of  a  recent  fracture  are  effusion 
of  blood  at  the  point  of  injury,  the  above-mentioned 
pain,  and  disturbance  of  function.  The  latter  two 
are  subjective  symptoms  dependent  upon  the  individ- 
uality of  the  patient,  and  therefore  are  not  decisive. 

THE    EXAMINATION    OF    A   FRACTURE 

should  be  gentle  and  rapid.  Frequently  inspection 
will  establish  the  fact,  so  that  manual  examination 
of  the  fragments  is  required  only  to  settle  certain 
questions.  In  every  case  the  examination  should 
clearly  determine  the  nature  of  the  fracture,  the  form 
and  position  of  the  fragments.  To  this  end  anaesthesia 
is  often  necessary,  especially  in  fractures  involving  a 
joint.  Whoever  in  doubtful  cases  resorts  to  anaes- 
thesia (chloroform,  ether,  ethyl  bromide)  by  prefer- 
ence, of  course  with  all  due  caution,  will  have  no 
cause  to  regret  it:    the  more  accurate  and   correct 


GEN"ERAL  KEMARKS   OK   FRACTURES.  9 

appreciation  of  the  conditions  will  result  in  a  shorter 
duration  of  treatment,  and  besides  an  exact  reduction 
can  be  effected  at  the  same  time. 

An  important  auxiliary  in  the  examination  is  men- 
suration. Since  the  broken  bones  are  nearly  always 
shortened,  the  demonstration  of  a  difference  in  length 
is  of  value.  This  is  not  meant  to  imply  that  a  tape 
measure  should  be  at  once  applied ;  on  the  contrary, 
the  correct  way  is  to  make  a  careful  inspection  from 
a  proper  distance  of  the  injured  limb  in  comparison 
with  the  sound  one,  both  being  in  symmetrical  posi- 
tion. After  judicious  exercise  in  the  clinic  and  later 
in  practice  slight  differences  can  often  be  better  appre- 
ciated with  the  eye  than  with  the  tape  measure.  Still 
mensuration  should  likewise  be  practised. 

COURSE  AND  REPARATIVE  PROCESS  OF  FRACTURES. 

A  fracture  is  followed  by  a  swelling  of  the  sur- 
rounding soft  parts,  which  is  due  partly  to  the  effused 
blood,  partly  to  the  infiltration  of  the  tissues.  The 
swelling  is  greater  in  proportion  to  the  severity  of 
the  injury  and  to  the  length  of  time  elapsed  between 
the  latter  and  the  replacement  of  the  fragments  and 
suitable  position  of  the  limb. 

These  conditions  of  course  are  not  without  influ- 
ence upon  the  system  in  general.  At  the  seat  of 
fracture  are  comminuted  bone  marrow  and  other  tis- 
sue elements,  together  with  the  effused  blood.  This 
is  the  reason  that  rise  of  temperature,  i.e.,  fever, 
occurs  soon  after  the  injury  in  healthy  persons  with 
recent  subcutaneous  fractures.  This  fact  may  be  ex- 
plained by  the  absorption  of  small  necrosed  tissue 


10  FRACTURES   AND    LUXATIONS. 

elements  at  the  seat  of  fracture,  but  might  be  more 
correctly  ascribed  to  the  action  of  the  blood  ferment 
which  is  absorbed  from  the  extravasation.  That 
fever  results  from  the  absorption  of  blood  ferment 
has  been  established  by  experiment. 

Smaller  or  larger  amounts  of  fat  enter  the  circula- 
tion from  the  crushed  bone  marrow  (for  fat  embolism 
xiicle  infra),  which  is  partly  excreted  by  the  kidneys. 
Therefore  in  some  cases  of  fracture  fat  is  found  in 
the  urine,  sometimes  associated  with  albumin  and 
casts. 

At  the  seat  of  the  injury  the  tumor  caused  by  the 
effused  blood  and  a  kind  of  inflammatory  swelling 
(oedema)  persists  for  some  days;  but  under  correct 
treatment  it  subsides  markedly  as  a  rule  by  the  end 
of  the  first  week.  The  effusioji  of  blood  then  mani- 
fests itself  on  the  skin  by  its  well-known  color  changes 
and  the  tension  diminishes.  When  the  swelling  is 
very  great  the  skin  at  the  seat  of  the  fracture  is 
sometimes  raised  in  serous  blisters;  these  do  not  dis- 
turb the  normal  course  when  the  treatment  is  correct 
and  no  additional  complications  occur,  but  the}'  call 
for  careful  disinfection  of  the  skin  and  an  aseptic 
dressing. 

At  the  point  of  fracture  there  is  formed,  or  discov- 
ered after  the  subsidence  of  the  swelling,  a  rounded 
fusiform  tumor  which  at  an  early  period  is  of  carti- 
laginous hardness,  the  ends  of  which  gradually  merge 
into  the  normal  outlines  of  the  bone.  This  is  the  so- 
called  callus.  As  the  latter  becomes  firmer  the  ab- 
normal mobility  of  the  fractured  part  diminishes. 
Finally  the  broken  ends  are  truly  fixed  by  the  callus: 
the  fracture  is  consolidated. 


GENERAL  REMARKS  ON  FRACTURES.        11 

It  is  a  noteworthj^  fact  that  this  course  forms  the 
rule.  Under  normal  conditions,  both  in  new-born 
children  and  in  most  advanced  age,  the  fracture  is 
consolidated  by  means  of  callus.  The  bulk  of  its 
substance  is  a  product  of  the  periosteum.  As  the 
latter  is  irregularly  torn  at  the  point  of  fracture, 
small  portions  of  it  being  possibly  displaced  into  the 
neighborhood  of  the  fracture,  a  periosteal  prolifera- 
tion occurs  at  these  places,  which  is  of  the  nature  of 
a  periostitis  ossificans.  The  medulla  of  the  bone  at 
the  same  time  is  not  altogether  passive ;  it  likewise 
exhibits  some  degree  of  callus  formation  (medullary 
callus).  If  we  picture  to  ourselves  this  callus  forma- 
tion on  a  fracture  without  marked  displacement  of 
the  fragments,  the  external  or  periosteal  callus  resem- 
bles a  mass  of  mortar  laid  all  around  the  broken 
ends,  the  internal  or  medullary  callus  occludes  the 
medullary  cavity  at  the  point  of  fracture,  and  the 
two  masses  are  united  by  the  so-called  intermediary 
callus  formed  sparsely  by  the  bone  itself. 

When  the  fragments  are  considerably  displaced  the 
callus  formation  of  course  is  much  more  abundant; 
in  such  cases  the  broken  ends  are  at  times,  as  it  were, 
plastered  together  by  a  large  mass  of  callus.  The 
callus  is  most  scanty  in  the  fractures  occurring  in 
children,  in  which  the  periosteum  has  remained  in- 
tact so  that  it  forms  a  closed  sheath  around  the  frac- 
ture and  prevents  displacement  of  the  fragments. 

While  callus  formation  was  formerly  divided  into 
temporary  and  definitive  (Dupuytren),  nowadays  we 
use  these  terms  only  in  so  far  as  after  the  healing  of 
a  fracture  in  the  ordinary  sense  further  changes  take 
place  for  a  long  time,  by  which  the  anatomical  rela- 


12  FRACTURES   AND   LFXATIONS. 

tions  of  the  seat  of  the  fracture  acquire  a  more  defin- 
itive character.  In  other  words,  after  a  fracture  is 
firmh'  consolidated  the  point  of  the  injury  does  not 
continue  unaltered  for  quite  a  long  period.  The  cal- 
lus, at  first  plentiful  and  spongj^,  hecomes  sparser 
and  firmer,  gradually  assuming  the  character  of  com- 
pact bone.  Whatever  is  not  required  in  a  mechani- 
cal sense  of  the  mass  of  callus  and  the  fragments 
undergoes  slow  absorption;  of  these  parts  only  so 
much  remains  as  the  bone  needs  for  its  mechanical 
function.  The  medullary  canal  likewise  may  be  re- 
stored. These  processes  of  absorption  and  ossification 
are  effected  very  slowly.  Plate  6  contains  illustra- 
tions showing  the  external  callus,  the  occlusion  of 
the  medullary  cavity  by  internal  callus,  also  callus 
tissue  of  a  spongy  and  compact  character,  and  the 
absorption  of  old  compact  bone  substance. 

UNTOWARD    ACCIDENTS    IN    FRACTURES. 

Mention  has  been  made  above  of  fat  embolism. 
While  the  absorption  of  small  quantities  of  fat  in 
fractures  is  very  frequent  and  as  a  rule  harmless,  the 
absorption  of  larger  amounts  of  fat  may  be  ver}'  dan- 
gerous and  even  fatal.  The  fat  is  derived  from  the 
comminution  of  the  bone  marrow,  sometimes  perhaps 
also  from  the  damaged  panniculus  adiposus  at  the 
seat  of  the  fracture.  The  fat,  which  is  liquid  at  the 
temperature  of  the  body,  may  pass  directly  into  the 
ruptured  veins  of  the  bone  and  thus  into  the  circula- 
tion ;  in  part  it  may  also  come  to  be  absorbed  and 
carried  along  by  way  of  the  lymph  channels.  The 
fat  then  enters  the  blood  current  and  leads  to  fat  em- 


GENERAL   REMARKS   ON   FRACTURES.  13 

holism  in  the  pulmonary  capillaries.  Whatever  fat 
passes  through  the  pulmonary  capillaries  enters  the 
arterial  circulation,  where  it  may  cause  embolism  in 
the  various  organs  (general  fat  embolism).  In  fatal 
cases  extensive  fat  embolism  has  been  demonstrated 
in  the  lungs,  in  the  central  nervous  system,  or  in  the 
capillaries  of  the  major  circulation.  The  treatment 
should  be  directed  toward  strengthening  the  activity 
of  the  heart  by  stimulants  so  as  to  favor  the  excretion 
of  the  fat  by  the  kidneys. 

Venous  thrombosis  and  embolism  in  subcutaneous 
fractures  are  rare  but  grave  accidents.  Cases  have 
been  reported  in  which,  in  the  course  of  a  healing 
fracture,  death  occurred  suddenly  with  symptoms  of 
asphyxia ;  the  autopsy  showed  embolism  of  the  pul- 
monary artery  due  to  venous  thrombosis  in  the  region 
of  the  fracture.  Other  cases  gave  rise,  in  a  similar 
manner,  to  embolic  infarction  of  the  lung,  and  in 
some  cases  which  recovered  the  diagnosis  of  embo- 
lism of  the  pulmonary  artery  could  also  be  made  from 
the  clinical  symptoms.  Venous  thrombosis  in  the 
region  of  the  fracture  often  causes  an  oedematous 
swelling  of  the  injured  extremity.  This  accident  has 
been  most  frequently  observed  in  fractures  of  the 
lower  extremity  (generally  in  the  third  week),  at 
times  in  relatively  mild  cases,  as  for  instance  recently 
after  fracture  of  the  patella. 

Lesions  of  the  blood-vessels  are  very  rare ;  they 
may  cause  profuse  effusions  of  blood,  and,  when  the 
arteries  are  involved  (rupture  of  the  anterior  and  pos- 
terior tibial  arteries  have  been  most  frequently  ob- 
served), aneurisms  and  gangrene.  Gangrene  due  to 
too  tight  bandaging  will  be  discussed  hereafter. 


14  FRACTURES   AND   LUXATIONS. 

Nerve  lesions  may  result  in  various  ways  in  cases 
of  fracture :  for  instance,  a  nerve  trunk,  such  as  the 
radial  and  peroneal  which  rest  upon  the  bone,  may 
suffer  simultaneous  injury  by  the  force  which  causes 
the  direct  fracture ;  or  a  nerve  trunk  may  be  wounded 
by  the  displaced  fractured  ends  (interposition) ;  or 
else  during  the  healing  the  nerve  is  compressed, 
sometimes  almost  surrounded,  by  the  callus  forma- 
tion. The  symptoms  of  course  depend  upon  the 
cause  and  the  distribution  of  the  injured  nerve. 
Operative  interference  (liberation  of  the  compressed 
nerve  from  the  callus  mass)  is  not  objectionable  and 
has  repeatedly  terminated  in  complete  recovery. 

Delayed  Callus  Formation. — While  callus  forms 
sometimes  in  excess  and,  though  rarely,  produces 
true  tumors  (osteoma,  enchondroma),  its  develop- 
ment is  occasionally  remarkably  retarded.  The 
cause  of  this  delay  can  seldom  be  ascertained.  Prac- 
tically it  is  important  that  in  such  cases  careful  ex- 
pectancy and  the  employment  of  appropriate  measures 
will  as  a  rule  result  in  consolidation.  Among  these 
measures  are,  besides  a  suitable  strengthening  diet, 
walking  about  of  the  patient  and  suspension  of  the 
broken  limbs  in  appropriate  dressings.  A  favorable 
effect  is  often  produced  by  establishing  venous  hyper- 
aemia  at  the  seat  of  the  fracture  by  the  application  of 
a  moderately  tight  rubber  tube  (drainage  tube)  above 
the  fracture,  while  the  distal  extremity  of  the  limb  is 
protected  by  bandaging.  More  vigorous  measures 
are  friction  of  the  fragments  against  each  other 
under  anaesthesia  or  perhaps  the  insertion  of  nails 
into  them  in  order  to  set  up  an  irritation  and  a 
stronger  reaction. 


GENEKAL   REMARKS   ON"   FRACTURES.  15 

Pseudartlirosis  is  the  term  applied  to  the  false 
joint  which  may  result  when  the  fracture  does  not 
consolidate.  Some  remarks  on  this  subject  will  be 
found  under  the  head  of  treatment.  Briefly  it  must 
be  remembered  that  the  formation  of  a  false  joint 
may  be  due  to  general  or  local  causes.  Chief  among 
the  general  causes  are  syphilis,  general  debility,  etc. 
At  the  seat  of  the  fracture  various  factors  may  give 
rise  to  a  pseudarthrosis,  mainly  extensive  local  con- 
tusion, such  as  occurs  in  serious  direct  fractures, 
especially  the  compound  varieties.  When  the  callus 
formation  is  permanently  at  a  minimum  the  forma- 
tion of  a  false  joint  will  be  the  natural  consequence. 
In  other  cases  callus  formation  may  be  normal  and 
even  excessive  and  yet  a  false  joint  may  result, 
namely,  when  soft  parts  are  interposed  or  when  the 
fragments  are  so  displaced  that  they  no  longer  come 
into  sufficient  contact ;  therefore  this  accident  is  more 
common  with  the  humerus  and  femur  than  in  limbs 
containing  two  bones.  It  is  readily  understood  that 
defective  immobilization  of  the  fracture  likewise 
favors  the  occurrence  of  a  pseudarthrosis. 

In  the  treatment  of  a  false  joint  the  minor  measures, 
such  as  friction  of  the  fragments,  the  insertion  of 
nails  or  ivory  pins,  are  usually  insufficient ;  as  a  rule 
resection  of  the  fractured  ends,  possibly  followed  by 
a  bone  suture,  will  be  required.  When  there  is  a 
marked  defect  of  bone  at  the  seat  of  the  fracture 
healing  can  be  effected  only  by  transplantation  of 
bone  between  the  fragments. 


16  FKACTURES   AXD   LUXATIONS. 


TREATMENT    OF    FRACTURES. 

The  treatment  aims  at  recovery  without  displace- 
ment and  with  good  function,  that  is,  consolidation 
of  the  fracture  with  the  fragments  in  good  position, 
without  injury  to  the  adjoining  parts,  especially  the 
neighboring  joints.  This  aim  nearly  always  requires, 
besides  replacement  of  the  fragments,  an  appropriate 
dressing  which  must  put  the  fracture  at  rest,  and 
therefore  must  include  not  only  the  broken  bone  but 
also  the  two  neighboring  joints.  The  dressings  may 
consist  of  pillows,  box  splints,  wire  cradles,  and  more 
complicated  apparatus;  in  case  of  necessity  and  for 
the  first  transportation  the  broken  arm  may  be  fast- 
ened to  the  thorax,  the  broken  leg  to  the  healthy  one. 
As  a  rule  use  is  made  at  present  of  circular  harden- 
ing (particularly  plaster  of  Paris)  bandages,  or  of 
splints,  or  of  extension  by  weights. 

There  is  no  question  that  fractures  may  be  treated 
in  various  ways,  by  the  exclusive  use  of  one  or  the 
other  method,  with  excellent  results,  if  the  surgeon 
possesses  some  skill  and  experience ;  but  in  order  to 
avoid  unfortunate  sequelae  it  is  desirable  that  he  pro- 
ceed in  general  according  to  definite  principles.  In 
early  times  physicians  sometimes  inclosed  the  recent 
fracture  in  plaster  of  Paris  on  their  first  visit  and 
left  the  dressing  for  weeks  undisturbed  until  the 
fracture  was  supposed  to  be  consolidated;  this  is 
wrong  in  principle,  and  recovery  with  more  or  less 
marked  displacement  is  the  necessary  result.  The 
first  dressing  of  a  fracture  must  be  based  on  the  fact 
that  the  place  of  the  injury  is  increased  in  thickness 


GENERAL   REMARKS   ON"   FRACTURES.  17 

by  the  swelling  of  the  soft  parts,  which  is  sometimes 
considerable ;  in  order  to  allow  for  this  swelling,  the 
first  dressing  must  be  well  padded.  Of  course  it 
should  be  correctly  applied  and  include  the  neighbor- 
ing joints,  but  make  allowance  for  the  greater  volume 
by  loose  material,  such  as  wadding  or  the  like. 

About  the  eighth  day  the  first  dressing  should  be 
changed;  for  then  the  swelling  has  certainly  partly 
subsided,  and  the  dressing,  having  become  loose,  is  apt 
to  permit  displacement  of  the  fragments.  The  new 
dressing  is  applied ,  after  careful  correction  of  the 
position  and  with  slight  padding.  For  the  latter  I 
prefer  the  wood  felt  supplied  by  the  firm  of  Hart- 
mann  in  Heidenheim,  as  it  is  both  soft  and  firm,  and 
keeps  the  skin  dry.  This  dressing  likewise  is  not  to 
be  the  final  one;  after  about  another  week,  or  say 
two  weeks  after  the  injury,  the  second  dressing  must 
be  changed.  At  this  time  the  swelling  has  fully 
subsided  and  the  seat  of  the  fracture,  though  sur- 
rounded with  callus,  is  still  movable,  so  that  a  final 
correction  of  the  position  can  be  easily  effected. 
This  third  dressing  may  in  ordinary  cases  remain 
until  complete  consolidation  has  occurred.  After 
that  a  light  and  removable  protective  dressing  may 
be  worn  as  long  as  required  in  each  case;  best  a  light 
splint  or  a  water-glass  and  chalk  dressing  cut  open. 

The  dressing  of  the  recently  injured  limb  should 
not  be  a  circular  plaster  bandage,  unless  special  con- 
ditions obtain  and  the  dressing  can  be  inspected 
daily.  A  splint  is  much  better  for  the  first  dressing. 
Disregard  of  this  rule  has  caused  much  mischief. 

In  some  cases  an  excessively  tight  plaster-of-Paris 
dressing  applied  for  the  purpose  of  compressing  the 


18  FRACTURES   AND   LUXATIONS. 

fracture  has  led  to  ischsemic  paralysis  and  contrac- 
ture, to  gangrene  at  the  seat  of  the  fracture,  or  even 
to  gangrene  of  the  whole  limb,  and  many  a  physician 
has  in  consequence  got  himself  into  trouble  by  being 
held  responsible  for  the  injury. 

All  the  cases  of  ischsemic  paralysis  and  contracture 
(Volkmann)  which  I  have  seen  were  due  to  a  plaster- 
of -Paris  dressing  applied  to  the  recent  fracture.  In 
such  a  case  the  prolonged  restriction  of  the  blood 
supply  to  the  muscle  causes  disintegration  of  its  ele- 
ments, it  loses  its  elasticity,  and  becomes  fixed  in  its 
contracted  position  (contracture).  The  irritability  of 
the  respective  nerve  is  intact ;  that  of  the  muscle,  ac- 
cording to  the  gravity  of  the  case,  is  more  or  less 
diminished,  and  at  times  absent. 

Among  the  splints  for  fractures  flexible  metal 
splints,  or  plaster  splints  (plaster-of-Paris  and  tow 
splints  of  Beely)  especially  prepared  for  each  case 
(see  Fig.  2,  Plate  42),  will  be  found  particularly  use- 
ful. .Of  the  former  I  prefer  the  w^ire  splints  devised 
by  Dr.  Cramer,  of  Wiesbaden,  or  padded  strips  of 
tin  of  different  length,  width,  and  thickness.  By 
keeping  these  on  hand,  padded  with  wadding  and 
covered  with  mull,  suitable  material  is  ahvays  ready 
for  fixing  a  broken  limb  in  any  position  by  means  of 
two  such  splints  and  a  few  bandages.  I  know  that 
many  of  my  pupils  have  these  splints  in  daily  use; 
the}'  are  also  employed  at  the  Munich  and  Greifswald 
policlinics. 

Extension  dressings  for  the  permanent  extension 
.by  weights  is  correctly  employed  not  only  in  frac- 
tures of  the  femur,  but  also  in  fractures  of  the  upper 
extremity  (for  instance,  of  the  neck  of  the  humerus, 


Fig.  1.— Ischgemic  Paralysis  and  Contracture  of  the  Forearm  Muscles  in  a 
Young  Man,  aged  17,  the  result  of  a  fracture  of  the  lower  end  of  the 
humerus  about  ten  years  before. 


20  FRACTURES   AND    LUXATIONS. 

of  the  elbow- joint),  of  the  spine,  etc.  The  technique 
for  all  these  dressings,  of  course,  must  be  acquired  by 
practice,  which  is  readily  afforded  in  every  surgical 
clinic. 

For  the  treatment  of  certain  fractures  other  methods 
are  also  in  use  nowadays,  which  have  given  excellent 
results  in  the  hands  of  some  specialists,  but  it  is 
doubtful  whether  the  methods  are  suitable  for  the 
general  practitioner.  It  is  unquestionable  that  the 
principle  of  the  suture  of  the  fragments  of  a  fractured 
patella  gives  superior  results  in  the  hands  of  the  sur- 
gical specialist;  it  is  admitted  that  the  treatment  of 
fractures  of  the  lower  extremities  by  ambulatory 
dressings  is  followed  by  good  results;  for  the  treat- 
ment of  the  typical  fractures  of  the  lower  epiphysis 
of  the  radius  it  is  even  recommended  to  dispense 
with  every  dressing  and  to  place  the  limb  simply  in 
a  mitella;  but  for  general  medical  practice  these  and 
similar  methods  are  not  suitable,  in  my  opinion. 

After  the  consolidation  of  the  fracture  great  im- 
portance attaches  to  the  after-treatment,  with  a  view 
to  restore  the  function  of  the  injured  extremity.  In 
this  respect  a  gratifying  change  is  to  be  noted  in 
recent  times,  much  more  being  done  in  order  to 
secure  good  results.  Even  in  connection  with  the 
later  changes  of  the  dressings  we  may  institute  care- 
ful massage  and  passive  movements  of  the  joints 
which  have  been  included  in  the  dressings  and  have 
become  somewhat  stiff.  Both  of  these  manipulations 
come  into  the  foreground  after  the  consolidation  of 
the  fracture;  at  the  same  time  warm  baths,  jet  baths, 
bandaging,  and  especially  the  employment  of  medico- 
mechanical  apparatus,  are  of  great  value. 


GENEKAL   llEMARKS   ON   FRACTURES.  21 

Particular  care  is  required  in  the  treatment  of 
fractures  involving  the  joints,  i.e.,  those  fractures 
which  implicate  the  articular  process  of  a  bone,  and 
therefore  give  rise  to  severe  lesions  of  the  joint,  whose 
capsule  is  filled  with  effused  blood.  In  such  cases 
the  aim  of  the  surgeon,  the  consolidation  of  the  frac- 
ture and  the  preservation  of  a  movable  joint,  is  most 
difficult  of  attainment.  The  indication  in  these  in- 
juries is  to  change  the  dressings  frequently,  during 
the  first  one  or  two  weeks  every  two  or  three  days, 
later  every  day.  To  favor  the  absorption  of  the 
effused  blood,  unless  it  has  been  removed  by  aspira- 
tion, we  must  resort  to  slightly  compressive  dress- 
ings, combined  with  massage  whenever  these  are 
changed,  and,  in  addition,  passive  movements,  fix- 
ation of  the  extremity  in  various  positions,  early 
active  movements,  and  the  application  of  mechanical 
apparatus.  To  carry  out  such  a  treatment  imposes 
much  labor  upon  the  surgeon,  but  the  reward  is  a 
brilliant  result  when  consolidation  of  the  fracture 
with  good  mobility  is  secured. 

It  might  almost  appear  surprising  that  I  finally 
discuss  badly  or,  rather,  unfavorably  united  fractures. 
In  spite  of  every  care  it^  may  happen  to  every  surgeon 
that  the  result  of  his  treatment  will  be  unsatisfac- 
tory ;  besides,  the  stupidity  and  intractability  of  the 
patients,  or  their  treatment  by  quacks,  furnish  oppor- 
tunities often  enough  for  treating  fractures  united 
with  deformity.  In  all  such  cases  improvement  of 
the  position  should  be  attempted  and  forced  without 
loss  of  time.  This  will  require  a  refracture  of  the 
bone,  perhaps  by  the  aid  of  an  osteoclast,  followed 
by  an  improvement  of   the   position   by  temporary 


22  FRACTURES   AND    LUXATIONS. 

manual  or  permanent  extension  by  heavy  weights 
and  pulleys,  and  finally  the  preservation  of  the  favor- 
able position  during  the  renewed  consolidation. 
Such  operative  interference  is  urgently  indicated  in 
badly  united  articular  fractures  likewise. 

GENERAL  REMARKS  ON  LUXATIONS. 

The  normal  mobility  of  joints  has  a  limit  of  ex- 
cursion which  in  many  cases  is  not  absolute.  Every 
joint  is  provided  with  some  arrangement  which 
checks  the  continuance  of  the  motion  beyond  a  cer- 
tain point.  This  check  is  effected  in  some  joints  by 
the  form  of  the  bone,  in  others  by  articular  liga- 
ments, and  in  a  few  by  the  muscles ;  accordingly  we 
use  the  terms  muscular,  ligamentous,  and  bony 
checks  of  articular  mobility.  While  the  bony  check 
is  absolute,  the  muscular  check  varies  with  the  elas- 
ticity and  distensibility  of  the  respective  muscles. 
We  need  but  recall  the  great  mobility  of  the  wrist- 
joint,  for  instance,  in  professional  piano  players  and 
the  movements  of  the  so-called  India-rubber  men; 
such  mobility  can  be  attained  only  by  practice  and 
the  lessening  of  the  muscular  check. 

Every  joint  has  its  limit  of  mobility,  and  when  the 
motion  is  continued  beyond  this  the  articular  appa- 
ratus suffers  an  injury,  laceration  of  portions  of  the 
capsule  or  the  ligaments,  that  is,  a  strain  or  sprain 
(distorsio).  When  this  lesion  of  the  articular  ap- 
paratus is  extensive  it  may  result  in  a  dislocation 
(luxatio),  in  which  the  articular  extremity  of  one 
bone  entirely  severs  its  normal  contact  with  the  other 
and  (with  few  exception;!;)  passes  more  or  less  com- 


GENERAL   REMARKS   ON   LUXATIONS.  23 

pletely  (Inxatio,  subluxatio)  through  the  ruptured 
capsule. 

As  in  the  case  of  fractures  so  in  luxations  we  dis- 
tinguish traumatic,  pathological  or  so-called  sponta- 
neous, and  congenital  forms.  The  latter  ar.e  due  to 
true  faults  of  development  or  to  displacements  which 
occurred  in  utero.  Spontaneous  luxations  result  only 
in  severe  alterations  of  the  joints  by  pathological  pro- 
cesses, especially  by  tuberculous  caries  or  extreme 
stretching  of  the  capsule  and  ligaments. 

Traumatic  luxations,  which  are  the  only  ones  to  be 
considered  here,  result  from  injuries  affecting  the 
joint  directly  or  indirectly ;  some  luxations  even  are 
due  to  active  muscular  action  in  sudden  violent 
movements. 

Luxations  are  naturally  more  frequent  in  men  than 
in  women,  and  in  adults,  to  the  onset  of  senile  age, 
than  in  children.  In  children  under  ten  years  luxa- 
tions are  extremely  rare.  It  is  noteworthy,  too,  that, 
according  to  Kronlein,  among  100  luxations  92.2 
affect  the  upper  extremity,  5  the  lower  extremity, 
and  2.8  the  trunk. 

Luxations  by  the  direct  action  of  a  force  are  rare. 
In  such  cases  the  trauma  acts  upon  the  region  of  the 
joint,  where  it  produces  the  luxation,  as  a  fracture 
results  in  the  bone  from  a  direct  force.  In  the  occur- 
rence of  indirect  luxations  there  is  an  increase  of  the 
joint  motion  beyond  the  extreme  limit  of  its  physio- 
logical excursion,  the  action  of  the  long  lever  of  the 
shaft  of  the  bone  overcoming  the  normal  check.  The 
short  lever  (the  condyle  or  the  articular  extremity 
which  is  luxated)  then  is  crowded  outward  in  a  defi- 
nite direction,  at  the  same  time  forming  a  fulcrum 


^4  FRACTURES   AND   LUXATIONS. 

(the  margin  of  the  socket,  capsule,  ligament,  or  a 
neighboring  bony  projection),  loses  its  contact  with 
the  opposite  articular  surface,  and  the  luxation  is 
accomplished. 

We  always  speak  of  a  luxation  of  the  peripheral 
portion  of  the  skeleton,  for  instance,  of  a  luxation  of 
the  humerus  when  the  dislocation  is  at  the  shoulder- 
joint,  and  designate  its  direction  by  the  course  taken 
by  the  peripheral  bone,  for  instance,  pr^eglenoid  lux- 
ation of  the  humerus  when  the  head  of  that  bone  has 
slipped  forward  in  front  of  the  glenoid  fossa. 

The  symptoms  of  a  recent  luxation  are  as  a  rule 
very  pronounced.  The  absence  of  the  articular  end 
at  its  normal  position,  its  presence  at  an  abnormal 
point,  cause  at  least  a  ver}^  marked  deformity,  which 
may  be  hidden  only  by  a  profuse  effusion  of  blood. 
The  position  of  the  dislocated  limbs  is  nearly  always 
quite  characteristic,  so  much  so  that  the  diagnosis 
can  frequently  be  made  by  simple  inspection.  In 
addition  the  position  in  the  several  forms  of  luxation 
is  as  a  rule  typical,  because  it  is  determined  by  the 
influence  of  certain  portions  of  the  capsules  and  liga- 
ments which  are  preserved  in  the  regular  forms  of 
luxation.  The  dislocated  limb  is  elasticall}'  fixed  in 
this  position,  that  is  to  say,  it  may  be  forced  by  ex- 
ternal pressure  and  traction  to  the  normal  limit  of  its 
excursion,  which  has  been  restricted  by  the  luxation, 
but  when  released  the  limb  springs  back  into  the  old 
pathological  position. 

The  last-mentioned  symptom  is  the  most  important 
for  the  differential  diagnosis  between  luxations  and 
fractures,  for  in  the  latter  this  elastic  fixation  is 
absent.     Other  important  points  in  luxations  are  the 


GBKERAL   REMARKS   ON"   LUXATIONS.  25 

absence  of  the  normal  bony  prominence,  the  possi- 
bility of  x>alpating  the  articular  end  in  an  abnormal 
position,  and  the  changed  direction  of  the  longitudi- 
nal axis  of  the  bone.  Mensuration  is  valuable  at 
times,  since  in  some  forms  of  luxation  there  is  no 
shortening  but  a  lengthening  of  the  limb. 

As  in  fractures  so  in  luxations  incidental  injuries 
may  be  present,  such  as  lesions  of  nerves  and  blood- 
vessels, extensive  laceration  of  the  soft  parts  sur- 
rounding the  joint,  ^en  v^ounds  of  the  overlying 
integument  w^hich  give  the  luxation  an  open,  com- 
pound character.  In  that  event  the  treatment  must 
be  carried  out  on  strictly  aseptic  principles. 

The  diagnosis  is  sometimes  rendered  very  difficult 
when  the  dislocation  is  complicated  with  a  fracture. 
As  a  rule  this  rare  complication  is  due  to  the  fact 
that  the  extraneous  force  continues  to  act  upon  the 
luxated  bone,  thus  causing  a  fracture  of  its  dislocated 
end.  The  treatment  of  course  aims  at  the  reduction 
of  the  dislocation.  This  was  formerly  done  in  a  very 
forcible  manner  by  powerful  traction,  with  the  aid  of 
three  or  four  assistants  or  the  use  of  block  and  tackle, 
which  sometimes  did  much  damage  (laceration  of 
large  vascular  and  nerve  trunks,  fractures,  etc.)  ;  but 
nowadays  reduction  is  offected  in  a  physiological 
manner  without  force,  as  a  rule  under  anaesthesia. 
The  rule,  that  the  surgeon  must  effect  reduction  by 
making  the  luxated  condyle  return  by  the  same  way 
in  which  it  reached  its  abnormal  position,  is  in  the 
main  correct.  The  manipulations  should  not  be  arbi- 
trary, but  should  be  based  on  an  accurate  knowledge 
and  observation  of  the  position  of  the  condyle,  the 
rupture   of   the  capsule,    and   the   surrounding  soft 


26    ■  FRACTURES   AND   LUXATIONS. 

parts.  "  The  anatom}^  of  the  hixation  determines 
pre-eminently  our  modern  procedure"  (Kroclein). 

While  these  conditions  will  be  considered  at  greater 
length  in  the  special  section  devoted  to  this  subject, 
a  description  of  the  further  procedures  after  reduction 
will  be  appropriate  here.  Under  normal  conditions, 
with  a  suitable  dressing  which  enforces  rest,  the 
laceration  of  the  capsule  is  repaired,  the  effused  blood 
is  absorbed,  and  the  irritation  of  the  joint  (sliglit 
synovitis)  subsides  in  a  week  or  two.  As  soon  as 
possible,  even  before  the  end  of  this  period,  massage 
and  careful  passive  movements  may  and  should  be 
begun.  If  these  set  up  fresh  pain  and  symptoms  of 
articular  irritation  thej'  may  be  suspended  or  contin- 
ued very  gently.  Beginning  with  the  third  week 
more  extensive  movements  and  active  exercises,  the 
use  of  apparatus,  etc.,  are  indicated;  finally  full 
restoration  of  function  must  be  secured. 

By  habitual  luxation  we  mean  the  frequent  recur- 
rence of  the  dislocation,  often  in  consequence  of  the 
most  insignificant  injury.  Such  patients  know  their 
condition  very  well  and  commonl}'  apply  to  the  sur- 
geon with  the  correct  diagnosis;  some  of  them  are 
able  to  reduce  their  luxation  themselves.  The  cause 
of  these  habitual  luxations  is  generall}'  a  marked 
lesion  of  the  joint  which  has  left  an  abnormall}"  wi- 
dened attachment  of  the  capsule.  The  treatment  rec- 
ommended is  more  prolonged  immobilization,  the 
injection  of  alcohol  for  the  purpose  of  effecting  a  cer- 
tain shrinking  of  the  tissues,  etc. ;  in  very  severe  cases 
resection  has  been  performed.  Perhaps  arthrotomy 
and  partial  extirpation  of  the  capsule  might  be 
attempted. 


GENERAL   REMARKS   ON   LUXATIONS.  27 

Under  certain  circumstances  a  luxation  may  be 
irreducible ;  it  may  happen  that  replacement  fails  in 
spite  of  the  most  careful  attempts  under  anaesthesia. 
The  cause  may  be  the  small  size  of  the  laceration 
of  the  capsule,  but  usually  it  depends  upon  the  inter- 
position of  adjoining  soft  parts ;  that  the  reduction 
may  be  very  difficult  or  impossible  when  complicated 
with  a  fracture  of  the  margin  of  the  socket  will  be 
readily  understood.  In  all  such  cases  the  luxation 
should  be  reduced  at  an  early  date  by  operative  inter- 
ference; the  reduction  must  be  forced  by  opening  the 
joint  as  far  as  may  be  necessary. 

When  a  dislocation  has  not  been  reduced  the  con- 
dition presented  is  that  of  an  old  luxation,  often 
enough  associated  with  the  formation  of  a  new  joint, 
a  nearthrosis.  Careful  examination  and  the  local 
condition  will  decide  what  steps  are  to  be  taken  in 
these  cases.  When  the  function  of  the  nearthrosis  is 
quite  good,  as  may  happen  in  rare  instances,  it  may 
be  left  undisturbed,  and  the  efforts  of  the  surgeon 
will  be  directed  toward  increasing  the  mobility  of  the 
new  joint  by  appropriate  exercises,  etc.  In  other 
cases  the  only  alternatives  are  resection  or  arthrot- 
omy  with  a  view  to  replace  the  luxated  condyle  into 
the  old  socket.  The  latter  should  be  the  normal  pro- 
cedure, because  such  cases  of  non -reduced  luxation 
will  come  ever  more  frequently  under  treatment,  and 
because  the  result  of  reduction  is  generally  far  better 
than  that  of  resection.  But  it  is  desirable  that  re- 
duction be  forced  as  early  as  possible. 


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Lit^h  Aflst  V  F  Reichhold.Munchcn 


Explanation  of  Plate   8. 

Fractures  of  the  Vault  of  the  Cranium. 

Fig.  1. — Gunshot  ivound,  from  u'ithoiit  and  from 
within  (artificial).  Portion  of  the  vault  of  the  cra- 
nium of  a  cadaver  at  which  two  shots  with  a  small 
charge  of  powder  were  fired,  one  at  the  outer,  one  at 
the  inner  surface.  Arrows  indicate  the  direction  of 
the  bullet.  We  see  that  the  wound  of  entrance  repre- 
sents a  round  perforation,  while  the  wound  of  exit 
shows  extensive  splintering — a  larger  and  irregular 
loss  of  substance.  The  illustration  shows  at  once 
that  the  old  theory  about  the  brittleness  of  the  glass 
plate  does  not  apply,  and  that  the  result  in  injuries  of 
*the  skull  rests  rather  upon  purely  mechanical  con- 
ditions. Professor  Thiersch,  of  Leipzig,  owns  the 
vault  of  the  cranium  of  a  suicide  who  killed  himself 
b}-^  firing  a  charge  of  small  shot  into  his  mouth ;  in 
that  specimen  we  find  the  same  splintering  of  the 
external  table  as  in  this  artificial  preparation.  (Au- 
thor's collection.) 

Fig.  2. — Minor  gunshot  injury  (artificial),  caus- 
ing merely  a  slight  indentation  on  the  surface  of  the 
skull,  but  an  extensive  splintering  of  the  inner  table. 
(Author's  collection.) 

Fig.  3. — Old  fracture  of  the  vault  of  the  cranium, 
united  with  depression  of  the  fragments  and  thick- 
ening of  the  bone  at  the  point  of  fracture.  We  see 
that  the  internal  table  w^as  more  extensively  splin- 
tered than  the  external.  (Pathologico-Anatomical 
Institute  in  Greifswald.) 

Fig.  4. — Vault  of  the  cranium  with  fissure  in  the 
left  parietal  bone  and  pronounced  diastasis  of  the 
right  half  of  tlie  lambdoidal  suture.  The  fissure  is 
in  direct  continuation  with  the  diastasis  of  the  suture. 
(Pathologico-Anatomical  Institute  in  Greifswald.) 

11 


Explanation  of  Plate   9. 

Fracture  of  the  Skull,  with  Rupture  of  the 
Meningeal  Artery. 

Fig.  1. — Section  of  a  skull  on  which  are  marked 
the  direction  and  extent  of  a  fracture  observed  by 
myself  and  immediately  transferred  at  the  autopsy 
by  drawing  and  measurement.  The  case  was  that  of 
a  laborer  (Dittmar),  aged  20,  who  fell  from  the  fourth 
stor}'  on  February  7th,  1879,  and  died  of  tetanus 
starting  from  a  severe  contused  wound  in  the  right 
trochanteric  region.  When  admitted  to  the  clinic 
there  was  a  suggillation  in  the  left  temporal  region, 
palpable  fracture  of  the  squamous  portion  of  the  left^ 
temporal  bone,  hemorrhage  followed  by  the  escape  of 
cerebro-spinal  fluid  from  the  left  ear,  paresis  of  the 
left  half  of  the  face  and  of  the  right  upper  and  lower 
extremities.  The  illustration  clearly  shows  the  black 
line  of  fracture,  adjoining  it  the  grooves  for  the 
branches  of  the  middle  meningeal  arter}-,  and  finally 
the  line  of  suture  between  the  left  parietal  and  the 
frontal  bone;  the  latter  can  be  best  traced  from  the 
point  where  the  section  passes  through  the  vault  of 
the  cranium.  Within  the  line  of  fracture  and  the 
distribution  of  the  posterior  branch  of  the  meningeal 
artery  a  circular  dotted  line  surrounds  the  slightly 
shaded  spot  wdiich  marks  the  point  where  the  effused 
blood  from  the  ruptured  artery  was  found  between 
the  skull  and  the  dui*a  at  the  autopsy.  (Personal 
observation.) 

Fig.  2. — Horizontal  section  through  the  skull  with 
its  contents.  A  large  effusion  of  blood  derived 
fi'oin  tJie  middle  meniiKjeal  artery  is  found  between 
the  skull  and  the  dura.  The  figure  clearly  shows  the 
compression  of  the  brain  that  may  result  from  such  a 
meningeal  effusion.  (From  Hutchinson's  "  Illustra- 
tions of  Clinical  Surgery,"  II.,  Plate  54.) 

13 


F^l 


Fig  2 


Lilli.Ansi:  v.F.Reichhold.Miinchcn. 


F^1 


Fig  2 


Lith  Anst  V  F  Rcichhold.Miincheii 


Explanation   of  Plate  10. 

Fracture  by  Compression  of  the  Base  of  the 

Skull. 

Fig.  1. — Transverse  fracture  of  the  base  of  the 
skull.  This  fracture  was  produced  artificially  by 
transverse  compression,  in  a  suitable  apparatus,  of 
the  closed  and  intact  skull  of  a  fresh  cadaver.  Un- 
der these  circumstances  we  can  notice,  as  is  well 
known,  first  a  certain  elasticit}",  a  slight  change  of 
form  resulting,  which  disappears  again  with  the  ces- 
sation of  the  pressure.  A  moderately  increased  pres- 
sure then  causes  a  transverse  fracture  of  the  base  of 
the  skull,  sometimes  passing  simply  through  the 
middle  fossa,  sometimes  also  through  the  parietal 
bone,  etc.  (Personal  observation.  See  also  Mes- 
serer,  "  Ueber  Elasticitat  und  Festigkeit  dermensch- 
lichen  Knochen,"  Plate  5.) 

Fig.  2. — Longitudinal  fracture  by  compression 
of  the  base  of  the  skull.  The  patient,  a  man  aged 
35,  was  injured  by  a  fall  upon  the  head  from  a  height 
of  ten  feet.  The  autopsy  showed  the  fracture  of  the 
base  of  the  skull,  passing  through  the  foramen  mag- 
num, delineated  in  the  illustration.  This  case  re- 
ported by  Hutchinson  corresponds  to  the  longitudinal 
fractures  of  the  base  of  the  skull  which  are  produced 
artificially  in  an  analogous  or  similar  form  by  com- 
pression of  the  closed  skull.  (Hutchinson,  "Illustra- 
tions of  Clinical  Surgery,"  I.,  Plate  30.) 


13 


Explanation  of  Plate   11. 

Fracture  of  the  Base  of  the  Skull  by  the 
Lower  Maxilla  and  the  Vertebra. 

Fig.  1. — Sagittal  section  through  the  base  of  the 
skull  and  the  left  maxillary  articulation  (normal). 
The  illustration  shows  not  only  the  relations  of  the 
niaxillaiy  joint,  the  articular  process  of  the  inferior 
maxilla,  etc.,  but  also  the  extremely  thin  portion  of 
the  base  of  the  skull  at  this  point.  It  is  intended  to 
show  that  a  force  acting  upon  the  inferior  maxilla,  if 
it  is  transmitted  to  the  ascending  portion  and  espe- 
cially to  the  articular  processes  (as  by  a.  fall  upon  the 
chin  when  the  mouth  is  open),  may  result  in  a  frac- 
ture of  the  base  of  the  skull,  as  stated  by  the  authori- 
ties. It  has  even  been  observed  that  the  articular 
process  has  passed  at  this  point  through  a  broad 
fracture  into  the  cavity  of  the  skull.  Such  injuries 
of  the  base  of  the  skull  are  not  apt  to  be  very  frequent, 
because  the  inferior  maxilla  itself  breaks,  and  besides 
the  thick  margins  of  the  bone  serve  to  protect  the 
thin  part  of  the  bone  of  the  socket.  (Author's  speci- 
men.) 

Fig.  2. — Fracture  of  the  base  of  the  skull  bj^  the 
pressure  of  the  on-crowding  spinal  column.  The  pa- 
tient, aged  (50,  had  fallen  head  foremost  to  the  ground 
from  a  considerable  height.  The  on-crowding  verte- 
bral column  caused  the  fracture  of  the  base  of  the 
skull  around  the  foramen  magnum.  This  observa- 
tion b}'  W.  Baum  {Archiv  fiir  klinische  Chirurgie, 
Bd.  XIX.,  S.  oSl)  is,  as  he  himself  has  shown,  of 
great  importance  as  illustrating  a  principle.  Similar 
indirect  fractures  of  the  base  can  be  produced  arti- 
ficially by  pressure  upon  the  vertebrae,  as  I  have  often 
convinced  myself. 


14 


F^g1 


Fy2 


Lith. Anst  v. F. Reichhold, Miinchen . 


Fig1 


ry2 


Lilh.Anst  V  r  Reichhold.MiJnchcn 


Explanation   of  Plate    12. 

Fracture  of  the  Base  of  the  Skull  by  Injury 
IN  THE  Nasal  Region. 

Figs.  1  and  2. — Section  and  anterior  view  of  a 
skull  in  which  a  fracture  of  the  base  has  resulted 
from  pressure  upon  the  region  of  the  nose  and  su- 
perior maxilla. 

The  specimen  is  derived  from  the  cadaver  of  a  man 
(Schumann),  aged  28,  who  suffered  a  fracture  of  the 
nasal  bones  and  the  lower  orbital  margins,  and  died  in 
consequence  with  symptoms  of  meningitis,  on  April 
12th,  18T6.  At  the  autopsy  the  illustrated  remark- 
able specimen  was  found,  which  is  now  in  the  collec- 
tion of  the  Path ologico- Anatomical  Institute  in 
Leipzig,  numbered  a  112. 

The  section  clearly  shows  the  upward  displacement 
of  the  nasal  and  cribriform  bones,  so  that  the  detached 
crista  galli  actually,  penetrates  into  the  anterior  of  the 
cranial  cavit}-.  The  anterior  view  likewise  shows 
the  displacement  of  the  nasal  bones,  together  with 
the  multiple  lines  of  fracture  of  both  lower  orbital 
margins. 

The  illustrations  were  made  from  a  photograph  of 
the  specimen.     (Personal  observation.) 


15 


II.     Fractures  of  the   Skull. 

It  is  a  noteworthy  fact  that  in  fractures  of  the  vault 
of  the  cranium  the  internal  plate  is  always  more  ex- 
tensively fractured  than  the  external,  and  the  frag- 
ments are  more  markedly  displaced.  Formerly  this 
fact  was  attributed  to  a  greater  brittleness  of  the 
internal  table,  for  which  reason  it  has  also  been 
called  tabula  vitrea.  More  recently  it  has  been  shown 
that  this  phenomenon  is  based  on  simple  mechani- 
cal relations,  and  that  in  injuries  of  the  vault  of  the 
cranium  the  plate  farthest  from  the  point  of  impact 
regularly  fractures  more  extensively.  A  glance  at 
the  illustration  on  Plate  8  substantiates  the  important 
fact  that  when  the  vault  of  the  cranium  is  injured 
from  within,  from  the  cavity  of  the  skull,  a  like 
greater  splintering  as  ordinarily  occurs  on  the  inter- 
nal table  takes  place  at  the  outer  table.  We  must 
conceive  that  when  a  force  acts  from  without,  the 
point  of  impact  at  the  vault  of  the  cranium  bends 
inward  for  a  certain  distance.  As  soon  as  the  limit 
of  elasticity  of  this  portion  of  the  bone  is  exceeded, 
splintering  occurs  at  this  point,  which  we  must  pic- 
ture to  ourselves  as  convex  toward  the  cranial  cavity, 
and  such  splintering  must  be  greater  than  on  the 
concave  side  upon  which  the  force  acts. 

On  specimens  illustrating  fractures  of  the  vault  of 
the  cranium  we  often  recognize  a  position  of  the  frag- 
ments which  will  now  be  readily  understood.     The 

29 


30  FRACTURES    AN"!)    LUXATIONS. 

splinters  are  depressed  below  the  level  of  the  vault, 
and  are  always  more  extensive  in  the  depth  than  on 
the  surface.  On  examining  severe  compound  frac- 
tures of  the  vault  of  the  cranium  we  must  expect  that 
the  splintering  of  the  bones  in  the  deeper  portions  of 
the  vault,  especially  about  the  internal  table,  will  be 
far  greater  than  that  on  the  surface.  The  treatment 
of  such  open  fractures  of  the  skull  requires  in  tlie  first 
place  that  the  external  wound  of  the  soft  parts,  which 
is  often  very  dirty,  be  rendered  perfectly  smooth  and 
clean ;  this  is  best  effected  by  careful  removal  with 
knife  and  scissors  of  the  bruised  and  soiled  portions 
of  tissue.  In  the  second  place  the  depression  of  the 
fragments  must  be  remedied,  and  this  calls  for  trephin- 
ing at  the  margin  of  the  fracture.  In  many  cases, 
in  order  to  secure  perfect  asepsis,  all  the  splinters  of 
bone  must  be  extracted.  Otherwise  the  management 
of  the  wound  strictly  follows  surgical  rules;  the  de- 
fect at  the  point  of  fracture  may  be  covered  sooner  or 
later  by  an  osteoplastic  operation  utilizing  neighbor- 
ing structures. 

The  reason  why  regard  to  asepsis  necessitates  such 
radical  measures  and  the  removal  of  all  splinters  of 
bone  rests  upon  the  possibility  or  probability  that 
septic  particles  may  have  penetrated  from  without 
between  the  fragments  of  the  bone;  for  we  find  in 
some  specimens  of  this  character  that  hairs  in  larger 
or  smaller  numbers  have  been  imprisoned  between 
the  fragments.  I  have  repeatedly  noticed  this  in 
specimens  at  the  pathological  institutes  of  Leipzig 
and  Munich.  The  explanation  of  this  fact  is  obvi- 
ously that  at  the  moment  of  the  injury  the  fragments 
gape  more  widely  than  subsequently,  and  that  the  ex- 


FRACTURES    OF   THE    SKULL.  31 

traneous  force  at  the  same  instant,  after  severing  the 
soft  parts,  presses  the  hairs  into  the  wound.  Thus 
at  the  moment  when  the  fragments  gape  more  widely 
some  hairs  of  the  patient  may  enter  between  them,  and 
later  may  be  held  so  firmly  as  not  to  be  loosened  even 
during  the  maceration  of  the  bone. 

In  recent  subcutaneous  fractures  there  is  hardly 
ever  an  indication  for  operative  interference  or  pos- 
sibly trephining.  Contrary  to  the  views  formerly 
maintained,  we  now  know  that  minor  indentations 
are  not  followed  under  all  circumstances  by  unfavor- 
able results  in  the  brain.  The  slight  diminution  of 
the  capacity  of  the  cranial  cavity  is  of  no  importance. 
It  is  true  in  such  cases  disturbances  may  exception- 
ally occur  later  on,  for  instance,  the  so-called  Jack- 
sonian  cortical  epilepsy,  etc.,  when  surgical  interfer- 
ence may  become  necessary. 

As  regards  fractures  of  the  skull  in  general,  it  is 
important  that  a  certain  amount  of  elasticity  of  the 
skull,  which  was  demonstrated  some  time  ago  by 
Bruns,  has  been  confirmed  by  modern  investigations, 
made  with  every  precaution,  by  means  of  the  best  in- 
struments. A  force  acting  upon  the  skull  will  pro- 
duce fracture  only  when  the  limit  of  its  elasticity  is 
exceeded.  This  applies  also  to  the  fractures  of  the 
base,  although  it  must  be  admitted  that  the  base  is 
the  weakest  part  of  the  entire  skull. 

It  is  readily  understood  that  fractures  of  the  base 
of  the  skull  can  be  produced  only  in  an  indirect  way. 
Formerly  the  theory  of  contrecoup  was  advanced  in 
explanation  of  such  injuries.  By  contrecoup  was 
meant  that  the  mechanical  influence  of  an  extraneous 
force  acting  upon  the  vault  of  the  skull  caused  a  cer- 


32  FRACTURES    AND    LUXATI0:N^S. 

tain,  somewhat  wavelike  motion  of  the  sm'rounding 
bony  parts,  and  that  the  continuation  of  this  impulse 
finally  i3roduced  the  main  effect,  the  fracture,  at  the 
opposite  point,  that  is,  the  base  of  the  skull.  This 
theory  of  the  contrecoup  has  lost  more  and  more  of 
its  importance  with  advancing  knowledge,  and  now- 
adays the  term  contrecoup  is  hardly  used  in  the  sense 
stated. 

Aside  from  the  fact  mentioned  above,  that  the  base 
is  the  weakest  part  of  the  entire  skull,  several  other 
factors  are  of  importance  as  explaining  sufficientl}^ 
by  the  mechanical  effects  the  occurrence  of  indirect 
fractures  of  the  base.  A  considerable  portion  of  such 
fractures  result  from  the  extension  of  fissures  from 
some  part  of  the  vault  of  the  cranium.  It  is  perfectly 
natural  that  injuries  of  the  head,  whether  resulting 
from  the  impact  of  an  external  object  or  from  the 
patient's  fall  upon  the  head,  usually  cause  severe  le- 
sions and  fractures  about  the  upper  or  lateral  portions 
(temporal  region)  of  the  cranial  vault.  Every  one 
who  has  had  opportunities  for  observing  a  number  of 
similar  cases  knows  that  a  large  j^ercentage  of  basal 
fractures  are  due  to  this  cause ;  the}"  are  simply  con- 
tinuations of  a  fracture  at  the  vault.  Another  pro- 
portion of  basal  fractures  are  caused  indirectly  by  the 
forcible  penetration  of  parts  of  the  facial  bones  or 
of  the  vertebral  column  into  the  base  of  the  skull. 
If  a  person  has  fallen  head  foremost  to  the  ground 
and  has  suffered  no  direct  injury  of  the  cranial  vault, 
pressure  upon  the  base  of  the  skull  about  the  foramen 
magnum  may  still  have  been  exerted  by  the  on- 
crowding  spinal  column.  In  this  way  the  skull  is 
fractured  as  by  a  direct  impact.     The  same  effect 


FRACTURES   OF   THE   SKULL.  33 

will  result  if  the  body  lands  upon  the  trunk,  and 
the  head,  as  it  were,  impales  itself  base  foremost 
upon  the  vertical  spine.  Such  fractures  are  extremely 
characteristic  (see  Plate  11)  and  may  also  be  pro- 
duced experimentally. 

Similarly  as  by  the  spinal  column,  a  basal  fracture 
may  be  caused  by  the  facial  bones,  though  such  cases 
are  far  more  rare.  Plate  12  shows  a  specimen  in 
which  a  force  acting  upon  the  nasal  region  drove 
the  nasal  bones  into  the  anterior  cranial  cavity  with 
characteristic  displacement  of  the  crista  galli.  On 
Plate  11  the  base  of  the  skull  near  the  maxillary  ar- 
ticulation is  shown  in  sagittal  section  in  order  to 
recall  the  fact  that  this  is  the  thinnest,  sometimes 
translucent  part  of  the  base  of  the  skull,  where  frac- 
tures have  been  observed  from  pressure  of  the  lower 
iaw,  perhaps  due  to  a  fall  upon  the  chin  while  the 
mouth  was  open. 

Another  group  of  basal  fractures  owe  their  origin 
to  compression  of  the  skull  as  a  whole.  It  is  in,  these 
forms  that  the  elasticicity  of  the  skull  is  manifested. 
When  the  compressing  force  continues  to  act  frac- 
tures result,  and  experiments  demonstrate  that  these 
fractures  assume  a  longitudinal  direction  when  the 
compression  is  longitudinal,  and  when  the  latter  is 
transverse  the  fracture  passes  transversely  through 
the  base  of  the  skull.  Of  course  the  lines  of  fracture 
are  not  always  identical,  but  in  the  main  they  are 
similar  in  character  (see  Plate  10). 

The  preceding  considerations  still  leave  unexplained 
the  rare  isolated  fractures  of  the  roof  of  the  orbit  and 
the  basal  fractures  in  gunshot  wounds.  The  cause  of 
the  latter  forms  is  now  admitted  to  be  the  effect  of 


34  FRACTURES   AND   LUXATION^S. 

hydrostatic  pressure.  It  is  not  surprising  that  in  the 
case  of  such  injuries  acting  upon  the  skull  as  a  whole 
the  weakest  part  suffers  fracture  or  fissure.  Ad- 
ditional theories  respecting  these  questions  will  be 
found  in  larger  works  on  this  subject. 

The  symptoms  of  a  basal  fracture  of  course  vary 
according  to  the  seat  of  the  fracture  or  the  skull  cav- 
ity implicated.  In  the  great  majority  of  cases  affect- 
ing the  middle  cranial  fossa  and  the  region  of  the 
ear,  there  is  hemorrhage  from  the  ear  of  the  injured 
side  (laceration  of  the  drumhead),  sometimes  escape 
of  cerebro-spinal  fluid  from  the  ear,  trickling  of  clear 
serous  fluid  in  considerable  quantity  after  the  hemor- 
rhage has  ceased  (the  fluid  is  free  from  albumin  but 
contains  much  chloride  of  sodium).  Frequently  we 
find  lesions  of  the  facial  and  auditory  nerves,  also  of 
the  trigeminus,  etc.  In  fractures  involving  the  ante- 
rior cranial  fossa  the  effused  blood  gravitates  in  the 
course  of  the  first  few  days  into  the  region  of  the  eye 
and  appears  as  an  ecchymosis  of  the  lids;  this  symp- 
tom, liowever,  does  not  possess  the  pathognomonic 
importance  formerly  ascribed  to  it.  Epistaxis  is 
likewise  frequent,  and  when  the  patient  is  resting  on 
the  back  or  when  the  posterior  portion  of  the  nasal 
cavit}'  is  injured,  the  blood  may  flow  into  the  phar- 
ynx and  be  swallowed,  occasionally  causing  hsema- 
temesis.  In  cases  of  basal  fracture  brain  symptoms 
will  never  be  absent.  Relatively  the  slightest  affec- 
tion of  this  kind  is  concussion  of  the  brain,  a  clinical 
concept,  marked  by  unconsciousness,  vomiting,  and 
disturbed  cardiac  activity,  usually  slowing  of  the 
pulse.  The  unconsciousness  is  of  variable  duration, 
rarely  exceeding  twenty-four  or  thirty-six  hours;   on 


FRACTURES   OF   THE    SKULL.  •       35 

regaining  consciousness  the  patient  sometimes  has 
forgotten  all  that  has  occurred.  Otherwise  the  symp- 
toms disappear  completely  and  recovery  follows. 

Much  more  serious  is  contusion  of  the  brain  which 
implies  grave  anatomical  alterations — hemorrhage 
into  the  brain  and  frequently  even  laceration  of  the 
brain  substance.  According  to  the  importance  of 
the  affected  portion  of  the  cortex  special  nervous 
symptoms  will  be  present,  due  to  the  loss  of  function 
of  certain  centres;  then  focal  symptoms  will  be  asso- 
ciated with  the  general  symptoms.  Meningitis  and 
encephalitis  are  frequent  sequelse. 

Occasionally  there  may  also  be  compression  of  the 
brain.  Clinical  observation  and  experiments  have 
demonstrated  that  a  relatively  large  portion  of  the 
cranial  cavity  must  be  implicated  in  order  to  produce 
symptoms  of  compression;  small  extravasations  do 
not  cause  symptoms  of  cerebral  compression,  nor  do 
depressions  of  the  cranial  bones  unless  they  are  un- 
commonly large.  (Escape  of  cerebro-spinal  fluid.) 
Such  symptoms  are  caused,  in  fractures  of  the  skull, 
mainly  by  rupture  of  the  middle  meningeal  artery, 
in  which  the  extravasation  of  blood  is  located  between 
the  dura  mater  and  the  bone  and  flattens  the  convex- 
ity of  the  brain  (see  Plate  9).  In  typical  cases  of 
this  character  the  early  symptoms  of  compression  of 
the  brain  subside,  the  patient  regains  consciousness, 
and  appears  to  be  on  the  road  to  perfect  recovery. 
Then  hew  symptoms  are  manifested ;  at  first  those  of 
irritation,  later  states  of  paralysis  and  depression 
with  renewed  loss  of  consciousness,  and  finally  pro- 
found coma.  In  that  event  the  patient  can  be  saved 
only  by  trephining  over  the  seat  of  the  extravasation, 


36      *  FRACTURES    AND    LUXATIONS. 

removal  of  the  latter,  and  if  necessary  ligation  of  the 
middle  meningeal  artery. 

In  other  respects  the  treatment  in  uncomplicated 
fractures  of  the  skull  is  purely  expectant.  Rest,  good 
nutrition  of  the  patient,  sometimes  by  means  of  the 
stomach  tube,  perhaps  the  local  application  of  ice,  and 
especially  the  prevention  of  external  noxious  influ- 
ences are  the  sole  requirements. 

It  is  still  an  open  question  whether  disinfecting 
solutions  should  be  injected  in  cases  of  bleeding  from 
the  ear.  I  believe  it  to  be  impossible  to  secure  com- 
plete disinfection  by  this  means,  and  I  only  carefully 
cleanse  the  external  auditory  canal,  but  thoroughly 
disinfect  the  auricle  and  the  surrounding  skin,  and 
cover  the  parts  with  sterilized  cotton.  The  injection 
of  fluid  might  be  the  means  of  causing  infection  of 
the  deeper  portions  of  the  wound  (meningitis). 

The  union  of  fractures  of  the  skull  is  osseous,  with 
remarkably  slight  callus  formation;  the  latter  cir- 
cumstance is  due  to  the  facts  that  there  is  little  dis- 
placement, that  the  fragments  are  at  perfect  rest,  and 
that  the  dura  mater  possesses  less  bone-forming  ca- 
pacity than  the  periosteum  of  the  tubular  bones. 
Only  rarely,  in  young  children,  defects  of  the  cranial 
vault  are  left  behind  after  fractures;  some  of  them 
are  complicated  with  meningocele. 


m. 

FRACTUEES  AND  LUXATIONS 


OF   THE 


INFERIOR  MAXILLA,  THE  THORAX,  AND 
THE  VERTEBRAL  COLUMN. 


Explanation  of  Plate  13. 

Forward  Luxation  of  the  Lower  Maxilla. 

Fig.  1. — Bilateral  luxation  of  the  loiver  max- 
illa^ artificially  produced  in  the  cadaver  and  dis- 
sected. The  beautiful  illustration  shows  the  sj'nip- 
toms  of  this  luxation :  the  wide  open  mouth  and  the 
chin  slightly  displaced  forward.  In  addition  the 
specimen  shows  the  position  of  the  articular  process 
of  the  lower  jaw  in  front  of  the  articular  tubercle ; 
the  latter  projects  free,  and  behind  it  the  socket  is 
empty.  Since  a  portion  of  the  masseter  has  been  re- 
moved we  see  further  the  joint  capsule  which  passes 
from  the  socket  to  the  dislocated  condyloid  process 
and  is  drawn  taut.  Quite  characteristic  is  the  tem- 
poral muscle,  laid  bare  by  dissection,  which  is  placed 
in  extreme  tension  by  the  dislocation  and  thus  leads 
to  an  actual  incarceration  of  the  articular  process  in 
front  of  the  articular  tubercle.  This  illustration  elu- 
cidates the  tension,  the  impossibility  of  closing  the 
mouth,  and  the  correct  method  of  reduction  (freeing 
the  luxated  condyle  by  downward  pressure  upon  the 
lower  maxilla).      (Author's  preparation.) 

Figs.  2  and  3  represent  the  normal  conditions 
with  the  mouth  closed  (Fig.  2)  and  open  (Fig.  3). 
The  specimen  is  the  same  as  in  Fig.  1,  the  masseter 
partly  dissected  off;  the  temporal  muscle  appears 
more  relaxed  when  the  maxilla  is  simplj'  opened  (not 
luxated),  that  is  to  say  it  is  not  so  tense  as  in  Fig.  1, 
and  still  less  so  in  Fig.  2,  with  the  mouth  closed. 

See  also  Fig.  1,  Plate  11. 


18 


J%.2 


Fig.  3 


Lith.  Anst  .v.  F.  Reichhold,  Miinchen . 


Fiy2^ 


Fig  3 


Fig.k 


Lilh  Anst  v.F  Rcichhold.Munchcn 


Explanation  of  Plate  14. 

Fractures  of  the  Lower  Maxilla. 

Fig.  1. — Recent  fracture  in  the  body  of  the 
lower  maxilla^  with  oblique  lines  of  fracture  in  the 
region  of  the  molar  teeth,  which  are  missing.  (Path- 
ologico- Anatomical  Institute  in  Munich.) 

Fig.  2  a  and  h. — Fracture  of  the  articular  proc- 
ess of  the  loiver  maxilla.  The  view  of  the  specimen 
from  within  (Fig.  2  h)  in  particular  shows  the  frag- 
ment with  its  pointed  end  displaced  downward,  and 
so  united  that  the  upper  end  of  the  condyloid  process 
stands  below  the  normal  coronoid  process.  The 
semilunar  fossa  is  partly  filled  by  the  displaced  frag- 
ment. The  influence  of  these  relations  upon  the 
position  and  mobility  of  the  lower  jaw  can  be  easily 
recognized.  (Pathologico- Anatomical  Institute  in 
Munich.) 

Fig.  3.  —  Interesting  recent  oblique  fracture 
through  the  body  of  the  inferior  maxilla  and  both 
articular  processes.  The  latter  lines  of  fracture 
can  have  been  produced  only  indirectly  by  a  fall 
upon  the  chin.  (Compare  Fig.  1,  Plate  11,  with 
explanation.)  The  body  of  the  maxilla  is  fractured 
at  the  same  time.  (Pathologico- Anatomical  Insti- 
tute in  Munich.) 

Figs.  4  and  4  a. — Hammond'' s  ivire  splint  for 
fractures  of  the  inferior  maxilla,  shown  in  Fig.  4 
a  applied  in  its  natural  position  to  the  bone.  (After 
Rose,  "Ueber  Kieferbriiche  und  Kieferverbande.") 


19 


Explanation  of  Plate   15. 

Fractures  of  the  Ribs  and  the  Sternum. 

Fig.  1. — Four  ribs  slioiving  old  united  fractures 
on  three  of  them.  The  fracture  is  readily  recogniz- 
able on  the  upper  ribs  in  the  illustration ;  on  the  third 
there  was  evidently  a  separation  of  a  splinter  which, 
however,  has  again  united.  The  fracture  is  in  the 
region  of  the  angle.  (Pathologico- Anatomical  Insti- 
tute in  Greifswald.) 

Fig.  2. — Recent  fracture  of  the  sternum^  artifi- 
ciall}^  produced  in  the  cadaver  and  dissected,  in  anal- 
ogy with  a  similar  observation  by  the  author. 
(Personal  observation.) 

Fig.  3. — Diastasis  betiveen  manubrium  and 
body  of  the  sternum  united  u'ith  displacement^ 
longitudinal  section  in  side  view.  The  specimen  is 
from  the  collection  in  the  General  Hospital  of  Vi- 
enna; it  is  derived  from  a  woman,  aged  42.  The 
displacement  of  the  upper  fragment  below  the  lower 
is  easily  recognizable.  The  specimen  corresponds 
exactly  with  two  observations  made  by  me  here  in 
living  patients;  in  both  cases  this  fracture  with  simi- 
lar displacement  had  resulted  indirectly  from  a  fall 
on  the  nape  of  the  neck  Avith  forward  flexion  of  the 
spinal  column.  The  displacement  here  illustrated 
could  be  reduced  without  difficulty  by  traction  by 
weights  by  means  of  Glisson's  suspension  apparatus 
applied  to  the  head,  the  thorax  resting  upon  a 
wedge-shaped  pillow  and  the  head  being  slightly  bent 
backward.  Union  took  place  in  good  position.  (The 
illustration  is  from  Gurlt,  "  Lehre  von  den  Knochen- 
briichen,"  II.,  S.  273.) 


20 


Fz^.1 


FM^.2 


Fig  3 


Lith  Anst  v  F.ReichhoId.MiJnchen. 


Li»h  Anst  V  r  Reichhold.Niinchen 


Explanation  of  Plate   16. 

Luxation  of  the  Cervical  Vertebra. 

The  illustrations  on  this  plate  are  drawn  from  na- 
ture. We  made  a  clean  ligamentous  preparation  of 
the  cervical  and  upper  dorsal  spine,  on  which  we  pro- 
duced first  a  unilateral  and  then  a  bilateral  luxation. 
Each  figure,  therefore,  is  strictly  true  to  nature. 

Fig.  1  a  and  h. — Unilateixd  luxation  (by  rota- 
tion) of  the  cervical  vertebr^ce,  lateral  and  posterior 
views.  It  is  clearly  apparent  that  the  fourth  cervical 
vertebra  is  so  displaced  on  the  fifth  that  the  articular 
surfaces  on  the  left  no  longer  come  in  contact.  By  a 
movement  of  abduction  (flexion  to  the  right)  a  dias- 
tasis of  this  joint  occurred,  and  then  by  a  forward 
rotation  a  complete  dislocation,  leading  to  an  inter- 
locking of  the  two  oblique  articular  processes.  The 
protrusion  of  the  fourth  vertebra  is  evident  in  the 
lateral  view ;  the  inclination  of  the  spinal  column  or 
the  head  to  the  right,  from  the  posterior  view. 

Fig.  2  a  and  b. — Bilateral  luxation  (by  flexioii) 
of  the  cervical  vertebrce.  Here  we  easily  recognize 
the  marked  protrusion  of  the  fourth  vertebra  beyond 
the  fifth,  and  the  bilateral  interlocking,  as  well  as  the 
straight,  unchanged  direction  of  the  spinal  column 
on  the  posterior  view.      (Author's  preparations.) 


31 


Explanation  of  Plate    17. 
Fracture  of  the  Cervical  Spine. 

This  illustration  shows  a  fracture  of  the  cervical 
spine,  involving  the  sixth  and  seventh  vertebrae, 
which  occurred  in  a  woman,  aged  33  (Augusta  Ah- 
rens),  who  was  admitted  into  the  Greifswald  clinic 
on  June  28th,  1880,  and  died  on  July  5th.  In  ac- 
cordance with  the  specimen,  which  is  preserved  in  the 
Pathologico- Anatomical  Institute,  and  a  photograph 
taken  at  the  time,  a  like  fracture  was  produced  in  a 
cadaver,  from  which  this  drawing  was  made. 

We  see  clearly  the  fracture  of  the  sixth  and  seventh 
vertebrae,  and  the  pronounced  upward  dislocation  of 
the  seventh  vertebra  behind,  whereby  the  spinal  canal 
is  much  narrowed  and  the  cord  severely  contused. 

In  the  Ahrens  case  the  contusion  extended  entirely 
through  the  cord.  Accordingly  the  symptoms  dur- 
ing life  were,  consciousness  undisturbed,  sensor}^  and 
motor  paralysis  of  the  trunk  and  the  lower  extremi- 
ties, also  disturbances  in  the  upper  extremities.  The 
limit  of  sensibility  in  front  and  on  both  sides  was  at 
the  height  of  the  third  rib.  Retention  of  urine  was 
present.  In  tlie  region  of  the  fifth  cervical  vertebra 
was  a  distinct  backward  projection ;  under  anaesthe- 
sia this  could  be  easily  reduced.  The  head  was  sus- 
pended by  weights  by  means  of  Glisson's  apparatus 
and  a  sling  around  the  head,  the  patient  resting  on 
a  portable  frame  well  padded  with  water  cushions. 
Death  ocr-urred  witli  symptoms  of  paralysis  of  respi- 
ration.    (Personal  observation.) 


22 


Lith.Anst  .v.F.Rcichhoid.MiJncherv 


Fig.1 


Fi^:j 


Figk 
Lilh  Anjt  v  F  Reichhold.Miinchen. 


Explanation  of  Plate    18. 

Fractures  of  the  Vertebra.     Traumatic  Ky- 
phosis. 

Fig.  1. — Fracture  of  the  fifth  cervical  verte- 
bra^ the  result  of  a  run-over  accident.  The  bod}'  of 
the  vertebra  has  remained  intact.  (Pathologico- 
Anatomical  Institute  in  Greifswald.) 

Fig.  2. — Fracture  of  a  sxnnous  process.  (Per- 
sonal observation.) 

Fig.  3. — Angular  kyphosis  hy  fracture  of  verte- 
brae. G.  Wolk,  aged  38,  on  May  24th,  1894,  fell 
from  a  scaffold  live  metres  high,  landing  with  his 
back  on  some  bricks.  When  he  regained  conscious- 
ness he  was  able,  with  the  support  of  his  comrades, 
to  walk  to  his  home,  a  short  distance  from  the  scene 
of  the  accident.  When  admitted  to  the  clinic,  on  May 
30th,  the  kyphosis  about  the  eighth  and  ninth  dorsal 
vertebrae  shown  in  the  illustration  was  found.  Pal- 
pation in  this  region  caused  acute  pain.  There  were 
no  nervous  symptoms. 

Fig.  4. — The  same  patient  with  the  plaster  jacket 
applied ;  this  removes  some  of  the  weight  from  the 
seat  of  the  fracture  and  protects  it  against  direct  or 
indirect  lesions.     (From  a  photograph  of  the  patient.) 


23 


III.    Fractures  of  the  Bones  of  the  Face. 

These  bones  are  so  accessible  to  examination  from 
without  or  from  the  nasal  and  oral  cavities  that  their 
fractures  hardly  ever  present  any  diagnostic  difficul- 
ties. These  fractures  should  nearly  always  be  looked 
upon  as  compound,  since  the  lesion  is  in  open  com- 
munication with  the  nasal  or  oral  cavity ;  it  is  note- 
worthy, however,  that  the  union  nevertheless  is  not 
as  a  rule  associated  with  dangerous  accidents. 

The  nasal  bones  suffer  direct  injury  only  by  a  blow 
or  a  fall.  Fracture  of  the  nasal  bones  and  of  portions 
of  the  bony  septum  lying  behind  them  usually  causes 
distinct  and  sometimes  great  deformity  (traumatic 
depressed  nose).  In  recent  cases  the  deformity  can 
be  remedied  by  the  insertion  of  a  dressing  forceps 
into  the  nasal  cavity.  Among  the  symptoms  the 
suggillations  and  hemorrhage  from  the  nose  are  easily 
understood ;  some  slight  cutaneous  emphysema  may 
result  from  the  passage  of  air  into  the  cellular  tissue 
about  the  seat  of  the  fracture  through  the  laceration 
of  the  mucous  membrane. 

Fractures  of  the  zygoma  and  the  upper  maxilla  are 
the  result  of  direct  lesions,  very  often  from  the  kick 
of  a  horse's  hoof;  they  are  therefore  frequently  com- 
plicated with  a  wound  of  the  skin.  The  diagnosis 
presents  no  difficulties;  the  treatment  consists  in 
keeping  the  oral  cavity  clean,  careful  administration 
of  a  liquid  diet,  and  of  course  reposition  and  appro- 

37 


38  FRACTURES   AND    LUXATIONS. 

priate  fixation  of  displaced  fragments  of  the  alveolar 
process.  This  is  best  effected  by  the  aid  of  a  dentist, 
who  may  often  also  preserve  loose  teeth.  Occasion- 
ally I  have  secured  good  union  most  simply  by  nail- 
ing a  fragment. 

Fractures  of  the  lower  maxilla  are  more  frequent; 
their  examination  and  diagnosis  from  without  and 
from  the  oral  cavity  are  so  simple  as  to  hardly  call 
for  remark.  In  fractures  of  the  bod}^  or  the  arch  of 
the  lower  jaw  a  typical  displacement  may  be  observed 
in  so  far  as  the  posterior  portion  of  the  bone  is  drawn 
upward  by  the  action  of  the  masseter,  while  the  an- 
terior portion  is  displaced  downward  by  the  action  of 
the  biventer  and  the  other  muscles  attached  to  the 
chin.  This  is  so  simple  as  to  require  no  illustration. 
The  only  difiiculty  presented  by  these  fractures  con- 
sists in  the  retention  of  the  fragments  in  good  position. 
Fortunately  nowadaj^s  we  are  no  longer  dependent 
upon  the  dressings,  splints,  and  apparatus  applied  to 
the  margin  of  the  lower  jaw  and  the  region  of  the 
chin  and  fastened  to  the  superior  maxilla  b}'  band- 
ages. By  the  aid  of  a  dentist  or  by  simple  contriv- 
ances the  fragments  are  fixed  by  small  splints  fastened 
to  the  teeth  of  the  two  broken  ends.  Only  where  the 
teeth  have  been  lost  or  under  other  special  circum- 
stances are  we  compelled  to  resort  to  the  older  meth- 
ods or  the  bone  suture  with  thick  silver  wire.  Of 
course  the  mouth  should  be  kept  as  clean  as  possible. 

Among  the  rarer  fractures  of  the  lower  jaw  those 
of  the  articular  process  maj-  be  mentioned  (Plate  14). 
The  rare  fracture  of  the  coronoid  process  results  from 
traction  of  the  temporal  muscles;  union  is  usually 
effected  with  marked  diastasis. 


LUXATIOK   OF   THE   LOWER  MAXILLA.  39 

Fractures  of  the  lower  maxilla  are  generally  of 
direct  origin,  though  indirect  fractures  may  result 
from  a  fall  on  the  chin  or  from  lateral  compression  of 
the  bone. 


LUXATIONS    OF    THE    LOWER    MAXILLA. 

Bilateral  forward  luxation  of  the  lower  maxilla  is 
very  frequent.  It  results  from  excessively  wide  open- 
ing of  the  mouth  (yawning,  vomiting,  etc.).  As  is 
well  known,  some  displacement  of  the  condyle  takes 
place  with  every  physiological  movement  of  the  lower 
jaw ;  when  the  mouth  is  opened  the  condyle  leaves 
the  socket  and  reaches  the  articular  tubercle.  The 
axis  for  this  movement,  that  is,  the  point  of  least 
motion,  is  situated  about  at  the  beginning  of  the 
mandibular  canal  at  the  lingula.  When  the  move- 
ment is  forced  the  condyle  may  pass  forward  beyond 
the  articular  tubercle,  when  it  again  enters  a  depres- 
sion in  which  it  is  virtually  imprisoned :  the  luxation 
is  complete.  The  powerful  traction  of  the  muscles, 
especially  the  temporal,  makes  the  dislocation  a  very 
firm  one. 

It  is  obvious  from  this  that  the  reduction  requires 
a  definite  manipulation.  The  lower  jaw  must  first 
be  pressed  and  pushed  downward  (best  by  pressure 
with  both  thumbs  inserted  into  the  mouth  upon  the 
alveolar  processes  of  the  maxilla)  and  then  forced 
slightly  backward.  In  this  way  the  condyle  comes 
to  rest  upon  the  articular  tubercle  and  the  luxation  is 
reduced.  During  the  reduction  we  feel  the  sudden 
cessation  of  the  resistance  opposed  by  the  muscles. 

The  symptoms  are  exceedingly  simple.     The  mouth 


40  FRACTURES   AXD    LUXATIONS. 

is  wide  open,  the  teeth  of  the  lower  jaw  project  far 
beyond  those  of  the  upper;  the  patient  is  unable  to 
close  the  mouth;  the  prominence  of  the  condyloid 
process  is  absent  from  its  normal  position  and  is  felt 
farther  forward.  When  the  forward  luxation  is  uni- 
lateral the  mouth  is  likewise  wide  open  and  the  chin 
is  slightly  displaced  toward  the  healthy  side.  The 
joint  capsule  generally  remains  uninjured  and  is 
merely  tensely  stretched  (Plate  13).  This  luxation 
does  not  occur  in  children.  The  prognosis  is  favor- 
able, but  at  times  there  is  a  marked  tendency  to  a 
recurrence  of  this  dislocation  (habitual  luxation  of 
the  lower  maxilla) . 

FRACTURES     AND      LUXATIONS     OF     THE     SPINAL 

COLUMN. 

"We  may  speak  of  typical  fractures  of  the  spinal 
column  which  occur  most  frequently  about  the  fifth 
and  sixth  cervical  and  the  lowest  dorsal  aijd  the  first 
lumbar  vertebrae.  These  fractures  are  alwaj^s  due  to 
great  violence  (fall  from  a  height,  imprisonment  in  a 
cave-in,  etc.).  This  is  evident  even  from  the  fact 
that  the  spine  as  a  whole  possesses  a  high  degree  of 
elasticity  and  mobilit}^  together  with  considerable 
firmness,  for  one-fourth  of  the  length  of  the  spinal 
column  consists  of  the  elastic  intervertebral  discs, 
which  permit  great  mobility.  The  mobility  of  the 
spine,  as  is  well  known,  can  be  materially  increased 
by  practice.  We  need  but  recall  the  extraordinary 
movements  of  the  so-called  India-rubber  men,  which 
result  in  almost  true  flexions  in  tlie  cervical  portion, 
at  the  junction  of  the  dorsal  and  lumbar  portions. 


FRACTURES   AND   LUXATIONS   OF   THE   SPINE.         41 

and  in  the  lumbar  portion  itself.  It  is  only  by  great 
violence,  by  displacement  beyond  the  limits  of  the 
possible  mobility,  with  simultaneous  muscular  fixa- 
tion of  the  spine  as  a  whole,  that  these  fractures 
occur. 

A  typical  symptom  of  these  vertebral  fractures, 
aside  from  some  amount  of  shock  which  ensues  after 
such  serious  injuries,  is  traumatic  kyphosis  at  the 
seat  of  the  fracture.  This  results  from  the  displace- 
ment of  the  fragments  so  as  to  produce  shortening, 
which  is  a  consequence  of  the  extraneous  force,  of  the 
traction  of  the  powerful  longitudinal  muscles,  and  of 
secondary  movements.  This  gives  rise  to  an  angular 
prominence  of  the  spine  on  its  dorsal  aspect,  which  is 
recognized  by  the  characteristic  projection  of  the  re- 
spective spinous  processes.  When  the  vertebra  is 
fractured  obliquely  instead  of  transversely  a  lateral 
displacement,  corresponding  to  the  direction  of  the 
line  of  fracture,  may  of  course  result. 

A  slight  degree  of  kyphosis  is  sometimes  hard  to 
determine ;  in  that  case  the  intense  local  pain  is  of 
importance.  Abnormal  mobility  and  crepitation  of 
course  cannot  be  demonstrated.  Incidental  injuries 
may  be  present  in  the  spinal  cord  and  the  nerves 
emerging  through  the  intervertebral  foramina. 
While  the  spinal  cord  is  well  protected  in  its  canal 
guarded  by  bony  arches,  and  by  its  soft  surroundings 
in  the  shape  of  the  spinal  dura  mater  and  the  cerebro- 
spinal fluid,  still  a  more  or  less  grave  contusion  fre- 
quentl}"  occurs  in  fractures  of  the  vertebrae  and 
displacement  of  the  fragments.  When  the  contusion 
extends  through  the  cord  the  symptoms  correspond 
to  the  distribution  of  the  sensor}^  and  motor  nerves  at 


42  FRACTURES   AND    LUXATIONS. 

and  below  the  seat  of  the  lesion,  and  manifest  them- 
selves as  paralysis  of  the  rectum,  bladder,  and  lower 
extremities  (paraplegia)  in  injuries  to  the  dorsal  por- 
tion ;  as  motor  and  sensory  paralysis  of  the  trunk  and 
arms,  difficult  respiration,  at  times  extreme  rise  of 
temperature  in  lesions  of  the  lower  cervical  portion ; 
or  by  an  early  fatal  termination  due  to  lesion  of  the 
respiratory  centre  in  injuries  to  the  upper  cervical 
portion  of  the  cord.  The  prognosis  of  these  fractures 
depends  upon  the  nature  of  the  complicating  injuries 
and  their  sequels.  Fracture  of  a  vertebra  per  se  may 
heal  by  osseous  union,  and  many  patients  recover 
from  the  injury  and  are  capable  of  more  or  less  hard 
work,  provided  the  spinal  cord  has  suffered  no  dam- 
age. But  when  symptoms  of  a  spinal  lesion  are  pres- 
ent the  case  is  always  serious.  Even  if  the  patient 
escapes  a  myelitis  other  dangers  threaten  :  the  paraly- 
sis of  the  bladder  as  a  rule  requires  catheterization 
several  times  a  daj',  and  although  this  should  be  and 
often  is  done  in  a  truly  aseptic  manner  so  that  no 
harm  results,  yet  in  practice  it  is  not  uncommon  to 
have  cystitis  occur  from  infection  by  means  of  the 
catheter;  this  is  followed  by  the  development  of  a 
septic  pyelonephritis,  caused  by  micro-organisms,  to 
which  the  patient  gradually  succumbs.  Another 
danger  threatens  by  way  of  the  anaesthesia  of  the 
paralyzed  parts.  Bedsores  are  apt  to  form,  not  alone 
acutely  by  the  influence  of  grave  trophic  disturb- 
ances which  occur  particularly  after  injuries  to  the 
cervical  spine,  but  also  from  pressure  owing  to  the 
anaesthesia,  especially  in  places  where  the  skin  is 
often  moist,  as  in  the  sacral  region.  No  patient  re- 
quires greater  care,   more  attentive  medical  super- 


FEACTURES   AND   LUXATIONS   OF   THE   SPINE.         43 

vision  and  watchfulness,  than  one  with  paralysis  of 
a  large  part  of  the  body  due  to  injury  of  the  spine. 
A  soft  bed  free  from  creases,  special  protection  for 
the  sacral  region,  the  heels,  etc.  (water  pillows  or 
millet  chaff  pillows),  frequent  change  of  position  by 
a  partial  turn  to  the  right  or  left  side,  extreme  clean- 
liness and  dryness  of  the  couch,  gentle  washing  with 
alcoholic  liquids,  sublimate  solutions,  etc.,  careful 
evacuation  of  the  urine,  and  watch  over  the  fecal 
discharges  which  the  patient  passes  under  his  body 
(diarrhoea  is  therefore  very  unfavorable)  are  indis- 
pensable. Modern  hospitals,  to  which  such  patients 
should  always  be  sent,  are  provided  with  special  aux- 
iliaries, such  as  portable  bed-frames  with  an  opening 
for  defecation,  and  other  apparatus  for  the  careful 
lifting  of  the  patient  (permanent  water  bed) . 

The  seat  of  the  fracture  does  not  always  call  for 
special  care.  In  fractures  involving  the  cervical 
spine  useful  traction  and  rest  of  the  injured  portion 
may  be  secured  by  means  of  Glisson's  sling  applied 
to  the  head,  and  extension  by  weights.  The  applica- 
tion of  a  plaster-of-Paris  jacket  in  Sayre's  apparatus 
has  been  successfully  made  in  recent  fractures,  but  it 
is  liable  to  subject  the  patient  to  great  risk.  Later 
on  protective  apparatus  (plaster-of-Paris  jackets)  are 
necessary.  Operative  interference  in  order  to  free 
the  cord  from  injurious  pressure  has  been  rarely  re- 
sorted to  and  is  not  often  indicated. 

Other  forms  of  fracture  of  the  vertebrae  are  of  slight 
importance.  Fractures  of  the  spinous  processes 
alone,  by  a  direct  force,  are  generally  harmless.  So 
are  fractures  of  the  transverse  processes ;  fractures  of 
the  vertebral  arches,  usually  about  the  lower  cervical 


44  FRACTURES   AND   LUXATIONS. 

vertebrae;  fractures  by  contusion,  with  spreading  of 
the  body  of  the  vertebra  by  compression  in  the  direc- 
tion of  the  longitudinal  axis  of  the  spinal  column. 

Among  luxations  of  the  spinal  column  those  in 
the  region  of  the  dorsal  and  lumbar  vertebrae  are  ex- 
tremely rare  on  account  of  the  anatomical  relations. 
Luxations  of  the  cervical  vertebrae,  however,  are 
more  frequent  and  of  practical  importance. 

Take  the  cervical  vertebrae  of  a  skeleton  in  their 
order  and  draw  through  the  canal  a  very  thick  rub- 
ber tube  so  that  the  several  vertebrae  are  in  contact 
with  each  other.  On  stretching  the  tube  it  will  be 
easy  to  separate  two  of  the  vertebrae  and  by  appro- 
priate displacement  put  them  in  a  luxated  position. 
There  is  no  better  way  of  studying  these  relations. 

We  distinguish  luxations  by  flexion  and  by  rota- 
tion of  the  cervical  vertebrae  (Hueter).  The  former 
result  from  forced  bending  of  the  head  against  the 
chest :  in  this  position  the  vertebrae  spread  apart  on 
their  posterior  surface,  there  will  be  tension  and  lace- 
ration of  the  ligaments  also  on  the  articular  processes, 
and  by  a  slight  simultaneous  displacement  forward 
of  the  upper  vertebra  the  luxation  is  effected  (Plate 
16,  Fig.  2).  Luxation  by  rotation  is  to  a  certain 
extent  a  unilateral  luxation  by  flexion,  yet  it  does 
not  result  from  flexion  but  from  abduction  toward 
the  side  remaining  intact  and  from  forward  rotation 
of  the  upper  vertebra  (Plate  10,  Fig.  1). 

The  symptoms  are  at  times  quite  characteristic. 
In  luxation  by  flexion  the  line  of  the  spinous  pro- 
cesses is  interrupted  in  atypical  manner;  sometimes, 
it  is  said,  the  interval  between  the  vertebrae  can  be 
felt  with  the  finger  from  the  mouth ;  the  neck  is  in- 


FRACTURES    OF   THE    RIBS.  45 

variably  markedly  bent  forward  and  the  head  is 
straight.  In  luxations  by  rotation  the  head  is  always 
inclined  toward  the  healthy  side  and  slightly  turned 
in  the  same  direction;  the  displacement  of  the  line  of 
the  vertebrae  and  of  the  spinous  processes  is  much 
less  pronounced.  Injury  to  the  cord  is  possible  in 
these  luxations ;  as  to  its  results  compare  the  remarks 
on  fractures  of  the  vertebrae.  Lesion  of  the  phrenic 
nerve  is  absent  when  the  luxation  is  below  the  fourth 
cervical  vertebra.  The  prognosis  depends  upon  the 
associated  injuries  and  the  result  of  the  attempted 
reduction.  In  luxations  by  rotation  complicating 
lesions  may  be  absent. 

Treatment. — Reduction  is  to  be  effected  under  pro- 
found anaesthesia ;  in  luxation  by  rotation,  by  means 
of  abduction  toward  the  healthy  side,  in  order  to 
loosen  the  interlocking,  followed  by  backward  rota- 
tion of  the  cephalic  portion  on  the  injured  side.  In 
luxation  by  flexion,  first  the  one  and  then  the  other 
side  is  treated  like  a  luxation  by  rotation  and  reduced. 
After  reduction  has  been  effected,  several  weeks'  fix- 
ation by  an  appropriate  dressing  is  required. 

Among  other  luxations  of  the  cervical  spine  men- 
tion must  be  made  of  luxation  of  the  head  (luxation 
between  atlas  and  occiput)  by  excessive  flexion  or 
extension  of  the  head,  and  luxation  of  the  atlas 
(between  atlas  and  axis) ;  both  of  these  are  generally 
fatal  from  complicating  lesions. 

FRACTURES    OF    THE    RIBS. 

Fractures  are  of  course  rare  in  the  lowest  ribs, 
which   are   very   movable,  and   the  highest,  which 


46  FRACTURES   AND    LUXATIONS. 

are  somewhat  protected  by  their  situation;  otherwise 
they  are  of  frequent  occurrence.  In  children,  owning 
to  the  extreme  elasticity  of  the  ribs,  fractures  are  very 
rare. 

Fractures  of  the  ribs  may  be  direct,  or  indirect 
when  the  thorax  is  compressed  in  the  transverse  or 
sagittal  diameter  (multiple  fractures  occur  especially 
in  the  axillary  line  or  at  the  angles).  The  diagnosis 
is  not  always  possible  from  the  displacement  at  the 
seat  of  the  fracture,  but  is  based  rather  upon  the  pain 
and  a  crackling  crepitation  frequently  perceived  on 
pressure.  Often  the  lung  is  injured  at  the  same  time. 
This  organ  may  be  pierced  directly  by  pointed  frag- 
ments; as  this  lesion  is  associated  with  perforation  of 
the  costal  and  pulmonary  pleura,  there  is  often  present 
not  only  hsemothorax  and  pneumothorax  but  also  a 
traumatic  cutaneous  emphj^sema  which  spreads  from 
the  seat  of  the  fracture  and  in  grave  cases  may  dis- 
tend the  cellular  tissue  of  the  whole  body.  In  that 
case  the  air  passes  from  the  alveoli  and  the  smallest 
bronchioles  of  the  injured  region  of  the  lung  into  the 
pleural  cavity  during  inspiration  and  expiration  and 
thence  extends  farther.  Barring  universal  cutaneous 
emphysema,  which  may  become  dangerous  by  its 
great  extent,  this  emphj^sema  is  not  a  serious  com- 
plication; usually  it  disappears  by  absorption  in  a 
few  days.     Hsemothorax  may  require  aspiration. 

Treatment. — The  complications  must  be  attended 
to.  Strips  of  adhesive  plaster  are  to  be  applied  to 
the  seat  of  the  fracture.  The  fracture  heals  by  bony 
union,  usually  without  marked  displacement. 


FEACTURES   OF   THE   STERNUM.  47 


FRACTURES    OF  THE    STERNUM. 

These  are  either  of  direct  origin,  when  they  are 
generally  very  serious  owing  to  the  lesion  of  internal 
organs,  or  they  result  indirectly  from  forward  flex- 
ion of  the  spinal  column  or  of  the  head  so  that  the 
chin  presses  against  the  upper  edge  of  the  sternum. 
In  this  way  the  sternum  is  compressed  in  its  longi- 
tudinal direction  and  cracked.  Fracture  of  the  ster- 
num has  also  been  observed  from  backward  flexion 
of  the  trunk,  that  is,  by  traction  (tearing) .  This  bone 
being  superficially  situated,  the  diagnosis  of  the  frac- 
ture is  not  difficult,  especially  when  the  fragments 
are  displaced  forward  or  backward;  see  Plate  15. 


TV. 
FRACTURES  AND  LUXATIONS 


OF   THE 


UPPER  EXTREMITY. 


Explanation  of  Plate    19. 
SuBCORACoiD  Luxation  of  the  Humerus. 

The  patient  was  a  man,  aged  G4,  who  was  injured 
about  three  weeks  before.  In  the  mean  time  the 
swelb'ng  which  must  have  been  present  at  first  has 
subsided,  and  the  outlines  of  the  damaged  shoulder 
can  be  recognized  without  difficulty.  '  The  observer 
sitting  down  facing  the  patient  will  see  the  condition 
shown  in  the  illustration  and  will  be  able  to  compare 
the  details  of  the  diseased  right  side  with  the  healthy 
left  side.  This  comparison  is  rendered  easier  by  the 
fact  that  a  position  has  been  chosen  for  reproduction 
in  which  the  right  and  left  side  of  the  shoulder  girdle 
are  symmetrical;  but  after  studying  the  details  here, 
it  will  not  be  hard  to  recognize  them  also  in  other 
positions  of  the  arm  and  when  the  region  of  the 
shoulder  is  somewhat  swelled. 

We  notice  the  almost  angular  projection  of  the 
acromion,  and  the  normal  rounded  outline  of  the 
shoulder  has  disappeared.  The  arm  is  abducted, 
slightly  separated  from  the  trunk.  The  longitudinal 
direction  of  the  arm  (longitudinal  axis)  points  up- 
ward under  the  coracoid  process,  or  into  the  region 
of  the  clavicle,  instead  of  to  the  acromion  as  on  the 
healthy  side.  The  external  contour  of  the  arm  is 
somewhat  bent  in,  an  angle  open  toward  the  outer 
side  being  recognizable.  As  compared  with  the 
healthy  side  the  arm  appears  elongated.  Finall}^ 
under  the  coracoid  process  a  bulging  may  be  noticed, 
which  corresponds  aV)out  to  the  upper  end  of  the  hu- 
merus in  its  changed  direction. 


26 


Lith.  Anst -v.F.Reichhold.Miinchen . 


Lith  Anst  v.r.Reichhold.Miinchen 


Explanation  of  Plate   20. 
SuBCORACOiD  Luxation  of  the  Humerus. 

The  case  illustrated  on  the  preceding  plate  conld 
be  correctly  diagnosticated  by  inspection,  taking 
cognizance  of  the  points  stated.  Palpation  confirms 
absolutely  that  the  condition  is  one  of  subcoracoid 
luxation. 

Plate  20  shows  an  anatomical  preparation  of  the 
same  luxation  artificially  produced  in  the  cadaver. 
The  dislocation  was  effected  by  extreme  abduction, 
which  resulted  first  in  an  axillar}'  luxation  and  then, 
hj  a  secondary  displacement,  in  a  subcoracoid  luxa- 
tion .     The  dissection  was  made  on  the  dislocated  arm. 

Here  we  likewise  notice  the  abduction,  the  abnor- 
mal longitudinal  direction  of  the  humerus  under  the 
coracoid  process,  and  its  slight  bulging  at  this  point. 
In  addition  we  may  observe  with  special  distinctness 
the  angular  projection  of  the  acromion  which  is  not, 
as  under  normal  conditions,  overtopped  by  the  rounded 
prominence  of  the  head  of  the  humerus.  The  cause 
of  the  broken  outer  contour  of  the  arm  is  now^  also 
apparent :  it  is  the  combined  result  of  the  direction  of 
the  deltoid  muscle,  which  descends  abruptly  from  the 
acromion  and  is  here  very  tense,  and  of  the  external 
contour  of  the  lower  half  of  the  arm  in  its  abducted 
position.  In  the  illustration  we  can  readily  distin- 
guish the  deltoid  muscle,  a  portion  of  the  pectoralis 
major,  below  its  point  of  insertion  the  biceps,  along- 
side the  latter  a  portion  of  the  brachialis  internus, 
and  lastly  a  narrow  strip  of  the  triceps. 


27 


Explanation  of  Plate   21. 

SuBCORACOiD  Luxation  of  the  Humerus. 

This  illustration  shows  a  deeper  dissection  of  the 
preparation  figured  on  the  preceding  plate.  The  del- 
toid muscle  is  separated  from  its  anterior  point  of 
origin  and  turned  over  so  that  the  tense  portion  which 
springs  from  the  acromion  is  visible  from  within. 
The  pectoralis  major  is  likewise  detached  above  and 
depends  loosely  between  its  costal  origin  and  its  in- 
sertion at  the  arm ;  the  pectoralis  minor  lies  on  its 
inner  surface.  The  coracoid  process  is  easilj"  recog- 
nized; the  white  coraco-acromial  ligament  passes 
outward  from  this  point  at  the  same  level;  the  points 
of  attachment  of  the  coraco-brachialis  and  the  short 
head  of  the  biceps  are  distinct.  At  the  lower  part  of 
the  arm  may  be  seen  the  stump  of  the  coraco-brachi- 
alis from  which  a  piece  has  been  excised,  the  biceps, 
and  alongside  the  latter  fibres  of  the  brachialis  inter- 
nus.  We  also  see  the  upper  portion  of  the  humerus 
with  the  long  biceps  tendon,  and  the  articular  carti- 
lage of  the  head  of  the  humerus.  The  caput  humeri 
is  partiall}^  hidden  by  the  muscles  inserted  at  the 
greater  and  lesser  tuberosities;  the  subscapular  mus- 
cle passes  inward  and  upward,  the  supra-  and  infra- 
spinatus outward  and  upward.  Finally  the  drawing 
shows  the  nerve  trunks  of  the  axilla,  with  the  axil- 
lary nerve  passing  from  behind  around  the  humerus 
into  the  deltoid.  It  will  be  seen  that  these  nerves  are 
stretched  b}'  the  subcoracoid  luxation  and  that  they 
are  liable  to  suffer  injury  from  the  pressure  of  the  dis- 
located head.  The  position  of  the  nerves  in  the  illus- 
tration is  a  product  of  the  dissection  ;  otherwise  their 
course  would  be  slighth'  different.  It  is  to  be  partic- 
ularl}'  recommended  that  the  preparations  here  shown 
be  reproduced  on  the  cadaver  and  demonstrated  in 
the  various  stages,  as  is  done  in  the  author's  course 
of  instruction. 

28 


M.  deltoid 


Upept  maj 


\      Proc  cora/: 


JVaxUl..^ 


M.  deltoid 


Plexu.^  brcvchial. 


M  peel-,  rnaj 


"M.pect:  mm 
^M coraco  -  brack. 


M.  biceps  br. 


Lith.Anst  V  r  Reichhold.Miinchen 


,  ..^ 


Fi^k 


Lilh. Anst  v. F.Reichhold, Miinchen . 


Explanation  of  Plate   22. 

SuBCORACOiD  Luxation,  of  the  Humerus;    Re- 
duction. 

This  plate  is  to  illustrate  the  several  steps  of  Kocli- 
er's  method  of  reduction  of  a  subcoracoid  luxa- 
tion. This  was  done  with  the  preparation  on  Plate 
21,  each  step  being  immediately  photographed.  The 
drawings  on  this  plate  were  made  from  these  photo- 
graphs. 

Fig.  1. — The  arm  is  adducted  until  the  elbow 
region  touches  the  trunk,  which  must  be  straight 
(first  step).  The  position  of  the  head  of  the  humerus 
has  undergone  no  material  change. 

Fig.  2. — The  arm  remaining  adducted,  it  is  rotated 
outward  by  the  aid  of  the  forearm  which  is  bent  at  a 
right  angle  in  the  elbow-joint  (second  step),  until  the 
forearm  lies  about  in  the  frontal  line  of  the  trunk. 
Some  resistance  is  experienced  and  the  force  em- 
plo3'ed,  of  course,  must  not  be  excessive.  The  head 
of  the  humerus  during  this  step  is  displaced  outward, 
aw^ay  from  the  coracoid  process  to  the  acromion,  as 
is  evident  in  the  illustration,  especially  by  the  greater 
distance  of  the  brachial  plexus. 

Fig.  3. — The  arm,  which  is  kept  adducted  and  ro- 
tated outward,  is  elevated^  that  is,  lifted  forward 
(third  step).  During  this  step  the  head  of  the  hu- 
merus begins  to  pass  through  the  rupture  in  the  cap- 
sule and  to  resume  its  normal  position. 

Jig.  4. — In  the  succeeding  inicard  rotation  (fourth 
step)  the  head  is  fully  reduced,  without  the  violent 
snap  which  always  indicates  that  the  reduction  was 
forced  and  not  effected  in  a  "physiological"  manner. 


29 


Explanation  of  Plate  23. 

Old  Subcoracoid  Luxation;  Fokmation  of  a 
New  Socket  on  the  Scapula,  and  Abrasion 
OF  the  Head  of  the  Humerus. 

Fig.  1  shows  the  two  bones  in  the  luxated  position, 
seen  from  in  front.  The  head  of  the  humerus  hides 
the  region  of  the  glenoid  fossa  and  is  situated  on  the 
anterior  surface  of  the  neck  of  the  scapula,  below  the 
coracoid  process.  We  see  the  free  anterior  surface 
of  the  head  of  the  humerus  covered  with  cartilage, 
and  the  margin  of  the  osseous  proliferation  at  the 
neck  of  the  scapula  which  surrounds  the  newly  formed 
articular  cavity.  The  humerus  is  slightly  abducted. 
The  mobility  of  this  abnormal  connection  is  ex- 
tremely small;  the  cause  of  this  fact  becomes  clear 
on  closer  inspection  of  the  bones  at  their  point  of 
contact. 

In  Fig.  2  the  two  bones  are  seen  again,  the  scapula 
in  anterior  view  as  in  Fig.  1,  but  the  humerus  turned 
about  180''  so  as  to  present  its  posterior  surface,  which 
faces  the  scapula.  On  the  scapula  the  glenoid  fossa 
appears  in  side  view,  considerabl}"  foreshortened,  its 
anterior  circumference  diminished  by  abrasion,  and 
immediately  adjoining  it  the  new^  socket  surrounded 
by  the  rather  uneven  bony  wall.  On  the  humerus 
likewise  can  be  observed  the  depression  caused  b}' 
abrasion  against  the  margin  of  the  glenoid  fossa,  and 
at  the  point  corresponding  to  the  anatomical  neck 
some  proliferations  of  bone  such  as  are  characteristic 
of  artliritis  deformans.  The  eburnations  present  at 
the  points  of  contact  of  the  two  bones  in  the  regionjof 
the  abraded  surfaces  unfortunatelj^  cannot  be  clearly 
delineated.     (Author's  specimen.) 


30 


Lith  Anst  v.F.Reichhold.Miinchen. 


\  ■■■ 


//^2 


-'  -./^ 


■r.'/- 


F,g3 

Lilh  Anst  v.r.Reichhold.Munchen 


Explanation  of  Plate   24. 
Fractures  of  the  Scapula. 

Fig.  1. — Fixicture  of  the  neck  of  the  scapula. 
We  see  the  line  of  fracture  at  the  neck,  the  displace- 
ment of  the  small  fragment  which  contains  the  artic- 
ular surface,  and  the  natural  downward  displacement 
of  the  fragment  together  with  the  arm.  Pushing  up 
of  the  arm,  however,  will  suffice  to  show  the  mobility 
of  the  fragments  and  the  perceptible  crepitation.  In 
this  figure  the  line  of  fracture  at  the  neck  has  been 
artificialh'  produced  and  so  drawn ;  but  as  a  rule  the 
neck  of  the  scapula  breaks  so  that  the  coracoid  proc- 
ess forms  part  of  the  displaced  fragment,  as  appears 
in  Fig.  2  by  the  line  of  fracture  jjassing  from  the 
lower  margin  of  the  articular  process  to  the  notch. 

The  other  line  of  fracture  shown  in  Fig.  2  passes 
obliquely  through  the  lower  margin  of  the  articular 
fossa,  and  therefore  indicates  the  detachment  of  this 
portion  from  the  lower  margin  of  the  socket.  (Per- 
sonal observation.) 

Fig.  3. — Lines  of  fracture  of  the  scapula  united  bj^ 
callus;  on  the  posterior  surface  their  course  through 
the  crest  of  the  scapula  was  very  distinct.  (Patho- 
logico- Anatomical  Institute  in  Greifswald.) 

The  stud}"  of  Fig.  1  on  this  plate  is  essential  for 
appreciating  the  points  which  are  of  importance  in 
the  differential  diagnosis  of  injuries  in  the  region  of 
the  scapula. 


31 


Explanation  of  Plate   25. 
Luxations  of  the  Clavicle. 

Fig.  1. — Upward  luxation  of  the  acromial  end 
of  the  clavicle. 

This  illustration  is  meant  to  facilitate  the  diagnosis 
of  this  luxation  in  the  living  patient;  it  is  mistaken 
with  remarkable  frequency  for  a  subcoracoid  luxation 
of  the  humerus.  In  our  Fig.  1  the  right  arm  is 
shown  slightly  drawn  up,  after  a  preparation  artifi- 
cially produced  in  the  cadaver  so  as  to  correspond  with 
a  photograph  of  a  living  patient  in  whom  the  char- 
acteristic displacement  was  most  marked  in  this 
position.  A  glance  at  the  illustration  shows  the  pro- 
nounced displacement  of  the  acromial  end  of  the 
clavicle,  which  is  otherwise  intact;  the  acromion  is 
in  normal  relation  to  the  arm  and  the  rounding  of  the 
shoulder  is  unchanged  in  other  resijects.  That  por- 
tion of  the  shoulder  girdle  which  is  normally  kept 
away  by  the  interposed  clavicle  from  the  trunk  is 
approximated  to  the  latter  and  the  axilla  is  almost 
obliterated ;  this  approximation  of  the  right  arm  be- 
comes most  marked  on  comparing  its  distance  from 
the  right  nipple,  which  is  much  less  than  on  the  oppo- 
site side. 

But  when  the  displacement  is  less  marked  and 
great  swelling  is  present,  how  is  this  luxation  to  be 
correctly  diagnosticated  ? 

A  single  manipulation  suffices :  the  patient  being 
seated  oi)posite  the  physician,  the  latter  follows  with 
both  hands  the  crests  of  the  scapuke  on  either  side 
from  behind  and  thus  reaches  the  point  of  the  acro- 
mion with  certainty  (Fig.  2).  The  position  of  the 
acromion  with  reference  to  the  prominence  of  the 
clavicle  will  immediately  decide  the  question. 

Fig.  3. — Forward  liuation  of  the  sternal  end  of 
the  clavicle.  The  illustration  requires  no  comment; 
it  is  accurately  drawn  from  a  preparation  on  the 
cadaver. 

32 


iUiz>U:, 


yfcrornion---[ 


Fiq  2 


Lith.  Anst  v. F. Reichhold, Miinchen 


Lilh  Ans(  V  F  Reichhold.Munchen 


Explanation  of  Plate   26. 

Fracture  of  the  Clavicle,  with  Typical  Dis- 
placement OF  THE  Fragments  and  Typically 
Altered  Position  of  the  Arm. 

The  seat  of  the  fracture  is  between  the  sternal  and 
the  middle  third  of  the  left  clavicle.  The  fragments 
override,  thus  shortening  the  clavicle.  The  sternal 
fragment  is  displaced  upward  by  the  traction  of  the 
sterno-cleido-mastoid;  the  external  fragment  is  dis- 
placed beneath  the  inner.  In  the  illustration  the  ster- 
no-cleido-mastoid is  easily  recognized;  postero-ex- 
ternally  the  trapezius  limits  the  outline  of  the  nucha. 
The  deltoid  can  be  recognized  at  once;  the  clavicular 
origin  of  the  pectoralis  major  has  been  detached  and 
ren:ioved  so  that  in  this  opening  we  may  see  the  first 
rib,  the  exact  position  of  the  fragments,  beneath  the 
lateral  fragment  the  subclavius  muscle,  and  finally 
and  particularh'  the  large  vessels  and  nerves.  Be- 
tween the  yellowish  brachial  plexus  and  the  blue  sub- 
clavian vein  a  small  strip  of  the  subclavian  artery 
(red)  is  visible. 

As  a  consequence  of  the  fracture  of  the  clavicle  the 
position  of  the  arm  is  changed :  it  is  approximated  to 
the  trunk  with  obliteration  of  the  axilla  and  it  also 
hangs  farther  down;  all  this  is  very  evident  in  the 
illustration,  but  the  forward  and  inward  displacement 
of  the  shoulder  region  cannot  be  easily  represented. 

Of  especial  importance  is  the  depicted  relation  be- 
tween the  fracture  and  the  large  vessels  and  nerves ; 
it  is  readily  understood  that  severe  lesions  of  the  ves- 
sels and  especialh'  of  the  nerves  may  result  from  the 
pressure  of  the  fragments. 


33 


Explanation  of  Plate   27. 

Traumatic   Separation    of    the   Epiphysis   at 
THE  Upper  End  of  the  Humerus. 

A  glance  at  Fig.  1  on  the  following  Plate  28  shows 
the  course  of  the  epiphyseal  line.  Obvioush",  as  in 
Fig.  1  on  this  plate,  we  are  dealing  with  bones  of 
young  persons  in  which  the  epiphyseal  lines  are  still 
present;  the  coracoid  process,  too,  has  not  3'et  under- 
gone osseous  union.  The  illustration  is  very  instruc- 
tive as  showing  how  the  epiphysis  remains  in  contact 
with  the  scapula  by  means  of  the  ligamentous  appa- 
ratus of  the  shoulder-joint  and  by  the  muscles  in- 
serted at  the  tuberosity  of  the  humerus;  some  shreds 
of  periosteum  adhere  to  the  epiph3'sis.  The  diaphy- 
seal end  in  its  characteristic  form  is  drawn  under- 
neath. Often  enough  the  separation  of  this  cartilag- 
inous union  is  so  extensive  as  to  lead  to  a  marked 
and  serious  displacement  of  the  shaft  t>f  the  humerus, 
especially  forward  and  inward;  sometimes  it  is 
remediable  in  no  other  way  than  by  operation. 

Fig.  2.— Picture  of  a  man  (Bertram,  1878)  with 
considerable  shortening  (arrest  of  growth)  of  the 
right  humerus  in  consequence  of  an  injury  at  the 
upper  end  of  the  bone  in  earl 5^  youth.  As  is  well 
known,  lesion  of  the  epiphj'seal  cartilage  is  not  rarely 
followed  by  an  arrest  of  its  physiological  production, 
that  is  to  sa}',  diminished  growth  of  the  injured  bone; 
this  is  most  marked  when  the  union  took  place  with 
the  fragments  much  displaced.  (Personal  observa- 
tion.) 


:}4 


Fy.2 


Lith.Aost  v.F  Reichhold.MiJnchen 


Acrorjiion 


F,^1 


^      '^Z      Humerus: 


n^2 


Fict  k 


Fig  3 

Lith  Anst  V  F  Rcichhold.Miinchen. 


Explanation  of  Plate   28. 

Fractures  at  the  Upper  End  of  the  Humerus. 

Fig.  1. — Course  of  the  epijjhyseal  line  on  the 
section  of  the  normal  hone.  The  epiphysis  at  the 
upper  end  of  the  humerus  really  consists  of  the  epi- 
physis of  the  head  and  the  apophyses  of  the  tuberos- 
ity. But  these  coalesce  so  early  into  one  hone  that 
practically  the  epiphysis  is  of  importance  in  this 
form.  The  elevation  of  the  epiphyseal  line  shown  in 
the  illustration  is  the  result  of  the  coalescence.  The 
knowledge  of  this  form  is  of  practical  importance 
because  not  rarely  we  can  discover  by  direct  palpa- 
tion the  diaphyseal  end  with  its  pointed  extremity 
and  lateral  declivity.     (Author's  collection.) 

Fig.  2. — Picture  of  the  shoulder  of  a  boy  of  14 
(Klinke,  1804),  who  had  suffered  the  displacement 
shown  by  a  traumatic  separation  of  the  epiphysis  at 
the  upper  end  of  the  humerus.  The  illustration  is  to 
recall  the  fact  that  this  displacement  is  best  recog- 
nized, not  from  in  front,  but,  as  here  shown,  from  the 
dorso-lateral  aspect.  The  diagnosis  will  be  easiest 
when  the  observer  stands  behind  the  patient  and 
takes,  as  it  were,  a  bird's-eye  view,  that  is  from 
above,  inspecting  the  injured  shoulder  and  at  the 
same  time  comparing  the  two  sides;  in  this  way  we 
observe  the  characteristic,  sometimes  almost  angular, 
projection  of  the  displaced  diaphyseal  end  of  the 
humerus. 

Fig.  I]. — Lines  of  fracture  drawn  in  the  anatomi- 
cal  and  the  surgical  neck  of  the  humerus. 

Fig.  4. — Old  fracture  of  the  upper  part  of  the  shaft 
of  the  humerus  united  with  marked  displacement; 
the  shaft  is  displaced  forward  and  inward.  (Au- 
thor's collection.) 


35 


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2  ^  •"  .2  -^  S  ?^> 


O    tH    _^  «4-i  Ti 


^  g^i  .^  ^  ^  S  S  c3  o  '  b 

g   -  bio^-5- 53  §  ^  fee     ^4 

LJ  ^^      t^      Q.>      (M       ^-    ~5       '—'    jj    _lj    __,  r"~H      ,— 

^         '-'         ^j    0)    CO  P    aT*'-'  ^  +=    *5  f^    CD  , . 

Z,  ^     ^     D  -^  ^     r/D     <,.     O  -S  -^  P>-  •"     9^ 


*5]  '  ^^  '-/^  SX*  ^^  ^^"^  f^l  T  — 

"=^  i  t:  5  G  ^  •"  «^  -5  .2  ^     S  S  • 
•  ^;:::  &/).^2  g.2  ^-^  ^     cc  -  ■ 


r/} 


p^  ^^^  a:-^  '-^  "^'^  ^    .•-  cD.oc 


<D      M   .r-l      ^^   TH      _      ^      CC      ©  ^^  '       ' 

rH     rrt        _      fl^     ^      i^  JlL      ,-<      ^ 


36 


1^ 


Fig.r 


W 


ng2 


/ 


'r\ 


^^r 


Fuj  -t 


■:cj^> 


Lilh  Anst  ^^F  ReichhoW.Miinchcn. 


Explanation  of  Plate   30. 

Fractures    at    the    Lower    End    of    the 
Humerus. 

Fig.  1  a  and  h. — Bones  of  a  child  (right  arm)  in- 
jured by  heavy  machinery.  In  Fig.  1  a  we  see  the 
transverse  fracture  and  the  fissure  in  the  shaft  of  the 
humerus,  also  the  partial  separation  of  the  inner 
and  middle  portion  of  the  lower  ejoiphysis  of  the 
humerus.  The  forearm  bones  of  the  some  patient 
are  represented  in  Fig.  1  h;  the  radius  is  normal;  the 
ulna  shows  a  longitudinal  fracture  causing  separa- 
tion of  the  olecranon.  The  arm  had  to  be  amputated. 
(Author's  collection.) 

Fig.  2. — Longitudinal  fracture  of  the  humerus 
extending  into  the  elhow-joint.  The  injury  was 
due  to  a  charge  of  small  shot  at  close  range.  The 
humerus  at  its  middle  was  completely  comminuted; 
the  lower  portion  exhibited  the  longitudinal  fracture 
shown.  The  patient  recovered  with  the  loss  of  the 
arm.      (Author's  collection.) 

Fig.  3. — Oblique  fracture  through  the  articular 
end  of  the  humerus  with  separation  of  the  eminen- 
tia  capitata  and  the  external  condyle.  Such  and 
similar  oblique  fractures  occur  in  all  possible  varia- 
tions.    (Author's  collection.) 

Fig.  4. — Typical  transverse  fracture  of  the  hu= 
merus  above  the  condyles,  with  longitudinal  fracture 
extending  into  the  joint,  so-called  T-fracture.  (Au- 
thor's collection.) 


37 


Explanation  of  Plate   31. 

Fractures   at    the    Lower  End   of  the    Hu- 
merus     AND      AT      THE      CaPITULUM      OF      THE 

Kadius. 

Figs.  1  and  2  show  the  epiphyseal  line  and  the 
epiphysis  at  the  lower  end  of  the  humerus  in  section 
and  on  external  view.  This  traumatic  separation  of 
the  epiphysis  in  its  pure  form  is  much  rarer  than  at 
the  upper  end  of  the  humerus. 

Fig.  3. — Fracture  at  the  lower  end  of  the  hu- 
merus above  the  condyles,, ivith  typical  displace- 
ment. An  attentive  observer  will  immediately  rec- 
ognize the  similarity  of  the  position  and  of  the 
posterior  outline  of  the  arm  to  that  in  posterior  luxa- 
tion of  the  forearm  (Plate  34).  The  bones  are  indicat- 
ed by  dotted  lines,  and  the  conditions  thus  made  evi- 
dent in  the  illustration  are  recognized  by  the  physician 
by  careful  palpation;  he  finds  the  olecranon  less 
markedly  projecting,  the  condyles  which  are  easily 
felt  are  in  normal  relation  to  the  forearm  bones,  and 
on  displacing  the  lower  end  of  the  humerus  laterally 
the  point  of  fracture  is  readily  discovered  by  the 
crepitation.  The  treatment  of  course  must  secure 
the  replacement  of  the  fragments,  not  rarely  and 
most  suitably  by  the  aid  of  extension  by  weights  and 
pulleys.     (Personal  observation.) 

Fig.  4  a  and  h. — Old  united  fracture  of  the  cap- 
it  alum  of  the  radius.  The  cartilaginous  edge  has 
a  rather  tumid  character;  the  separated  fragment 
has  united  in  a  displaced  position,  which  is  particu- 
larly marked  in  the  section  (Fig.  4  h).  The  speci- 
men was  obtained  by  resection  (Friederike  Lemke, 
aged  2S,  1889.  Three  months  before  admission  she 
had  fallen  on  her  outstretched  arm). 


38 


Fig. 2 


Lith.  Anst  .v.F  Rcichhold.Miinchcn . 


Li»h  Anst  v.r  Reichhold.Miinchen. 


Explanation  of  Plate  32. 

Deformity  of  the  Arm  after  Articular 
Fracture  at  the  Lower  End  of  the  Hu- 
merus. 

Figs.  1  and  2. — Old  oblique  fracture  at  the  loiver 
end  of  the  humerus,  tuith  the  formation  of  a  cu- 
bitus valgus.  The  osseous  preparation  shown  in 
Fig.  1  is  an  accidental  finding  in  a  cadaver.  We 
observe  the  alterations  following  this  old  articular 
fracture  and  presenting  the  character  of  a  slight 
grade  of  arthritis  deformans,  namely,  tumid  thicken- 
ing of  the  capitulum  of  the  radius,  atrophic  con- 
ditions of  the  articular  ends  with  their  cartilaginous 
covering,  sparse  thickening  of  the  bone  in  their 
neighborhood.     (Author's  collection.) 

In  Fig.  2  the  same  condition  may  be  recognized  in 
the  living  patient.  This  was  a  man,  aged  34  (John 
Janker,  1884,  Surgical  Policlinic,  Munich,  No. 
1,140),  wdiose  deformity  was  caused  by  a  fracture 
two  years  previousl}',  which  had  united  obliquely. 
The  illustration  was  drawn  from  a  photograph. 

As  we  meet  wnth  genu  valgum  and  genu  varum, 
Avhich  occasionally  result  from  trauma  and  intra- 
articular fracture,  so  we  may  observe  also  a  cubitus 
varus  or  valgus  after  an  unfortunate  fracture  at  the 
lower  end  of  the  humerus.  In  ever}^  hinge  joint 
such  displacement  and  termination  are  possible  after 
a  separation  or  an  oblique  fracture.  The  measures 
by  which  such  results  may  be  avoided  are  exact  re- 
position of  the  fragments  and  keeping  them  in  good 
position  either  by  splints,  the  arm  being  flexed  or 
extended,  or  by  extension  by  weights  and  pulleys  in 
straight  or  flexed  position,  possibly  by  the  aid  of 
lateral  weighting  of  the  fragments  (sand  bags)  or 
suitable  lateral  traction.  Frequent  inspection  wdll 
be  required. 


39 


Explanation  of  Plate   33. 

Outward    Luxatiox    of    the    Forearm,  with 
Separation  of  the  Internal  Condyle. 

Of  the  lateral  luxations  of  the  forearm  the  outward 
is  more  frequent  than  the  inward  variety'  and  is  usu- 
ally associated  with  separation  of  the  internal  con- 
dyle. The  strong  internal  lateral  ligament  is  not 
torn  even  by  a  powerful  force  (in  an  abduction  move- 
ment at  the  elbow  as  in  the  production  of  a  valgus 
position),  but  the  bone  is  often  separated. 

Fig.  1  shows  the  lateral  displacement  of  the  bones 
so  that  the  ulna  articulates  with  the  lateral  part  of 
the  trochlea  and  on  the  eminentia  capitata,  while  the 
capitulum  of  the  radius  projects  free.  The  separated 
internal  condyle  is  still  connected  with  the  ulna  by 
the  internal  lateral  ligament.  The  drawing  was 
made  from  an  artificial  preparation  in  the  cadaver. 

Fig.  2. — In  this  illustration  the  luxation  shown  in 
Fig.  1  is  easily  recognized.  The  contours  of  the  arm 
are  otherwise  little  changed;  especially  is  there  an 
absence  of  the  projection  of  the  olecranon  character- 
istic of  backward  luxation.  The  prominence  of  the 
capitulum  of  the  radius  is  obvious  on  inspection 
alone.  Palpation  would  confirm  this  finding,  es- 
pecially when  movements  of  pronation  and  supina- 
tion are  made.      (Personal  observation.) 


40 


Lith.Anst  .v.F.Reichhold.Miinchcn . 


Li»h  An$t  v  F  Re»chhold,Munchen. 


Explanation  of  Plate   34. 
Backward  Luxation  of  the  Forearm. 

The  drawing  was  made  from  nature  after  prepara- 
tions on  the  cadaver.  The  position  shown  (about  at 
a  right  angle)  on  the  one  hand  was  particularly 
appropriate  for  representing  the  details,  and  on  the 
other  hand  it  was  rendered  necessary  by  the  size  of 
the  small  plates.  In  this  injury^  as  a  rule,  the  arm 
occupies  a  more  obtuse  angle. 

The  minute  anatomical  details  are  made  very  clear 
by  Fig.  1.  We  see  the  shaft  of  the  humerus  and  its 
lower  articular  end;  beneath  it  and  abnormally  dis- 
placed backward  the  capitulum  of  the  radius  and  the 
articular  cavity  (cavitas  sigmoidea  majora)  at  the 
upper  end  of  the  ulna.  Very  interesting  here  is  the 
delineation  of  the  external  lateral  and  the  annular 
ligament,  which  is  strictly  true  to  nature.  At  the 
anterior  side  the  biceps  with  its  tendon,  beneath  it 
one  margin  of  the  brachialis  internus,  behind  the 
humerus  the  triceps  with  its  insertion  at  the  point  of 
the  olecranon  can  be  recognized. 

Fig.  2  shows  this  form  of  luxation  in  the  living 
patient.  We  recognize  the  rounded,  turban -like 
prominence  of  the  capitulum  of  the  radius,  which, 
together  with  the  olecranon,  projects  abnormally 
backward.  When  we  form  a  mental  picture  of  the 
longitudinal  axis  of  the  humerus  we  become  at  once 
aware  that  it  does  not  coincide  below  (as  under  nor- 
mal conditions)  with  the  articular  end  of  the  forearm 
bones,  but  is  divided  into  a  short  posterior  and  a  long 
anterior  portion.  Corresponding  to  this  is  the  char- 
acteristic alteration  of  the  posterior  contour. 


41 


§  o2c»53a?fl^fl.2a:S^ 


y.         ^  S^  ^  >.^l:5-2  ^  -  <« 


c  o  CD  ^  f^  '^  «  ;^  t;^       <i>  .S 


hri 


-M 


03 


[^ 


o 

S       ^  H  .,  J^-^  S  ?^  H  5  ^^  ^  fl  .2 


02^     - 


g    rt  H  ^    ^^  ^    fl  .2 

k?     >^         ^  ?r.  s  '^  ^  "^  ^^      2  ^  -^  ^ 
/5      P         S2-Ba2^0^^-'grt^^ 

o  -1  H  .^  ^-^  O  .P  ^  775 


P  r^    5    -Oi    2    CD    r»  _^  rrr  ^    M  •--,    ^    CS 


H  S^a   g     .   Sd   ^   ^   o^ 

P  r^      2      -Oi     2     CD     aj^r^^     M-r^     !^     TO 

§  .^  o  S  2  S-2  ^^lnS-^  o^  2 

^  s::2«^rt2i2'^'+^2fl'c3^ 

g  ^  ?^  2  8  §  ^'^  ^^  2  ^-5 


^«'    i-<    1-^    I— '  m:    <_>    ^    ij    ^-'    Lj    ^ 
42 


M ulnar  ext 


CapU  rod-. 


M.uncofu 
'quart. 


Sf.  ulnar,  mt^:^^ 
Fig  1         M.flex  di^  coiriprof 


OLe-crcuion 


ry2 


■^. 


Lith  Anst  v.F  Reichhold.Miinchcn 


Explanation  of  Plate   36. 

Isolated  Luxation  of  the  Capitulum  of  the 
Radius  in  Fracture  of  the  Ulna  in  the 
Upper  Third,  with  Marked  Displacement 
of  the  Fragments. 

Fig.  1  shows  the  more  miuute  anatomical  details 
of  this  typical  injury,  as  they  appear  in  an  artificial 
preparation.  The  nlna  with  its  fragment  displaced  at 
a  distinct  angle  strikes  the  eye  at  once;  the  capitu- 
lum  of  the  radius  is  also  readily  recognized.  Be- 
tween the  head  of  the  radius  and  the  olecranon  the 
anconseus  quartus  muscle  shows  very  clearly ;  below 
the  ulna  we  see  the  flexor  digitorum  communis  pro- 
fundus and  the  ulnaris  internus;  above  the  ulna  the 
ulnar  is  extern  us. 

Fig.  "2. — The  same  injury,  which  was  artificially 
produced  in  the  cadaTer,  dra^m  by  the  aid  of  a  pho- 
tograjDh  from  a  case  observed  during  life.  The  posi- 
tion of  the  arm,  the  angular  flexion  in  the  ujDper 
portion  of  the  ulna,  and  the  ^Drominence  of  the  capi- 
tulum  of  the  radius  are  characteristic.  Close  behind 
and  below  the  head  of  the  radius  the  projection  of  the 
external  condyle  can  be  made  out.  This  injury  is 
not  rarely  misunderstood,  and  when  neglected  can  no 
longer  be  thoroughly  and  completely  cured.  It  re- 
quires osteotomy  at  the  seat  of  the  ulnar  fracture  and 
operative  reduction  or  resection  of  the  head  of  the 
radius.  It  is  hoped  that  this  illustration  will  con- 
tribute toward  a  better  understanding  of  this  typical 
injury. 


43 


Explanation  of  Plate   37. 

Fracture   of   the   Olecranon  and   the   Coro- 
NOiD  Process. 

Fig.  1. — Fracture  of  the  olecranon.  The  draw- 
ing was  made  from  an  artificial  preparation  in  the 
cadaver.  We  see  the  ulna  with,  the  separated  olecra- 
non and  the  diastasis  between  the  two  fragments 
which  during  life  is  effected  by  the  traction  of  the 
triceps.  Of  course  the  position  adds  to  the  effect, 
since  the  diastasis  of  the  fragments  is  considerable 
when  the  elbow  is  flexed,  and  can  usually  be  overcome 
when  the  arm  is  completely  extended.  The  olecra- 
non is  at  the  same  time  slightly  detached  or  twisted. 
It  is  very  clearty  evident  that  a  fracture  of  the  olec- 
ranon cannot  exist  without  a  wide  opening  of  the 
joint;  the  cartilaginous  surface  of  the  lower  end  of 
the  humerus  is  free ;  at  this  point  of  course  we  find 
the  effusion  of  blood  which  results  from  the  injury. 

Looking  at  this  illustration  with  a  view  to  the 
treatment,  it  is  quite  evident  that  the  first  require- 
ment in  fracture  of  the  olecranon  is  extension  of  the 
arm  at  the  elbow-joint,  aspiration  of  the  blood  if  the 
effusion  is  large,  and  an  approximation  of  the  upper 
fragment  by  traction  effected  by  means  of  a  strip  of 
adhesive  plaster  applied  in  the  form  of  a  sling. 

Fig.  2. — Old  bone  preparation  of  a  fracture  of  the 
olecranon  healed  by  ligamentous  instead  of  osseous 
union.      (Author's  collection.) 

Fig.  o. — Illustration  of  a  separation  of  the  coro- 
noid  process. 


44 


M  tnceps' 


OlecKanorv ,  -  \^ 


Eig3 


i%^ 


Lith.Anst.v.F.Reichhold.MiJnchen^ 


F^g1 


EU32 


Fuj.3 


Lith  Ansfv  F  Reichhold.Munchen 


Explanation  of  Plate   38. 

Fractures  in  the  Middle  of  the  Forearm. 

Fig.  1. — The  illustration  shows  the  unfavorable 
position  of  the  fragments  in  fractures  of  the  middle 
of  the  forearm  which  presents  itself  not  rarely  in 
recent  fractures,  and  now  and  then  in  old  fractures 
where  osseous  union  failed  to  occur  and  a  pseudar- 
throsis  resulted.  The  drawing  was  made  from  na- 
ture, the  patient  being  a  boy  who  recently  came  under 
treatment.  In  this  case  the  fragments  could  be  re- 
placed under  ansesthesia,  and  very  good  union  w^as 
obtained  by  extension  of  the  arm  in  the  elbow  and 
careful  fixation  by  means  of  a  long  dorsal  splint. 

Fig.  2  shows  a  similar  angular  position,  but  the 
injury  is  older ;  the  radius  has  undergone  firm  bony 
2tnion,  while  the  ulna  is  still  movable,  in  a  condition 
of  pseudarthrosis ;  both  bones  are  bent  in  an  equal 
degree.  The  result  shown  in  the  specimen  was  prob- 
ably due  to  insufficient  fixation  of  the  fracture,  pos- 
sibl}'  to  a  dressing  which  was  too  short  and  failed  to 
include  the  two  neighboring  joints,  a  blunder  often 
committed  by  quacks.     (Author's  collection.) 

Fig.  3  shows  a  most  important  condition  in  a  rela- 
tively harmless  form :  the  two  bones  are  connected 
at  the  iDoint  of  fracture^  fortunatel.y  not  by  a  mass 
of  bone  but  in  the  form  of  a  nearthrosis;  from  each 
bone  springs  a  conical  projection  at  whose  point  is  a 
kind  of  joint  surface  which  articulates  with  that  of 
the  other  bone.  It  is  clear  that  a  faulty  position  of 
the  two  bones  (pronation)  or  the  pressure  of  a  firm 
circular  dressing  may  cause  the  coalescence  of  the 
callus  of  the  two  bones,  when  their  fracture  is  in  a 
corresponding  position.     (Author's  collection.) 


45 


Explanation  of  Plate   39. 

Fracture  op  the  Radius.     Lower  Epiphyseal 
Line  of  the  Forearm  Bones. 

Fig.  1. — Isolated  fracture  of  the  radius  above 
its  middle  and  the  effect  of  the  biceps  on  the 
2DOsition  of  the  upper  fragment.  In  this  illustra- 
tion, which  is  drawn  exactly  from  nature  (artificial 
preparation),  we  see  the  forearm  with  the  hand  and  a 
portion  of  the  arm.  The  forearm  is  in  pronation. 
The  upper  fragment  of  the  radius,  however,  under  the 
influence  of  the  biceps,  is  in  supination;  for  this  mus- 
cle, as  is  well  known,  produces  supination  and  flexion 
of  the  supinated  forearm.  We  recognize  the  supina- 
tion of  this  upper  fragment  by  the  position  of  the 
tuberosity  of  the  radius  (the  point  of  insertion  of  the 
biceps)  and  especially  by  careful  inspection  of  the  line 
of  fracture :  the  lower  fragment  shows  on  the  fractured 
surface  a  small  inferior  defect  caused  by  the  forma- 
tion of  a  dentation  at  the  upper  fragment ;  the  denta- 
tion and  the  defect  do  not  face,  but  the  former,  by 
outward  rotation  of  the  upper  fragment,  i.e.,  by  its 
supination,  has  been  displaced  nearly  180^.  In  view 
of  these  facts  it  is  evident  that  even  in  isolated  frac- 
ture of  the  radius  the  ctrm  must  be  dressed  in  the 
supine  position. 

Fig.  2. — Epiphyseal  lines  at  the  loiver  end  of 
tJie  radius  and  ulna,  after  a  dry  preparation.  True 
separation  of  the  epiphyses  of  tliese  bones,  especially 
of  the  radius,  is  not  rnre  in  children.  As  a  conse- 
quence of  such  injuries  I  have  observed  serious  dis- 
turbances of  growth.     (Author's  collection.) 


40 


M  biceps 


F^l 


Fig  2 


Lith  Anst.v.F  Reichhold.MuRchen. 


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48 


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Lith  Anst  v  F  Reicbhold.Munchen. 


Explanation  of  Plate   42. 

Keplacement   and   Dressing   of    the    Typical 
Fracture  of  the  Radius. 

Fig.  1,  drawn  from  a  photograph  of  the  patient, 
shows  how  the  surgeon  is  assisted  during  the  i^eplace- 
ment  of  the  fragments  in  typical  fracture  of  the 
epiphysis  of  the  radius.  One  assistant  pulls  upon 
the  thumb  and  fingers  of  the  injured  hand,  in  the 
manner  shown,  the  other  assistant  exerts  counter- 
pressure  on  the  arm.  The  surgeon  then  can  place  the 
fragments  in  the  desired  position  by  direct  pressure 
upon  the  seat  of  the  fracture. 

Fig.  2. — Application  of  a  Beehfs  plaster-of- 
Paris  splint  after  replacement  is  effected.  The  fore- 
arm may  suitably  rest  upon  the  patient's  thigh,  the 
hand  being  flexed  in  the  volar  and  ulnar  direction. 
In  this  position  the  application  of  a  plaster-of-Paris 
splint  with  hemp  or  jute  fibres  is  easily  made.  But 
no  splint  should  project  beyond  the  metacarpus; 
the  fingers  must  remain  free.  (After  a  photo- 
graph.) 

Fig.  3. — Illustration  of  the  dressing  devised  by 
Professor  Eoser.  The  forearm  and  hand  in  com- 
plete supination  rest  upon  the  wooden  splint  so  pad- 
ded that  the  hand  is  in  volar  flexion,  the  fingers  again 
being  free. 

Recently  Professor  Petersen  has  urged  that  the 
arm  after  replacement  of  the  fragment  should  be 
simply  placed  in  a  mitella,  the  hand  being  pendulous, 
and  that  splints  should  be  dispensed  with.  In  many 
cases  this  can  certainly  be  done  and  it  may  be  inter- 
esting to  know  that  the  same  thing  was  proposed 
some  time  ago  by  Hutchinson  ('"  Illustrations  of  Clin- 
icar Surgery,"  II.,  110).  In  the  majority  of  cases, 
however,  this  will  not  be  feasible  in  medical  practice, 
if  only  for  the  reason  that  it  requires  very  careful  and 
frequent  examination. 

49 


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Lith  Ansi  v. F  Rcichhold, MiJnchen . 


Explanation  of  Plate   44. 

Incorrect  and   Correct   Mode   of   Reduction 
IN  the  Typical  Luxation  of  the  Thumb. 

The  i^ecluction  of  the  typical  luxation  of  the 
thumb  was  in  former  times  often  performed  quite 
inco)Tectly,  and  false  statements  and  drawings  are 
still  found  in  many  books.  As  in  analogous  lux- 
ations of  all  hinge  joints  no  force  should  be  emplo^'ed ; 
forceps  such  as  were  formerl^y  used  with  a  view  to 
exert  powerful  traction  must  be  altogether  rejected. 
Any  traction  renders  the  reduction  more  difficult, 
for  while  it  continues  the  muscles  and  the  tendon  of 
the  flexor  pollicis  longus  hug  the  neck  of  the  meta- 
carpal head  and  form  a  real  obstruction  to  reduction. 
This  is  partly  shown  in  Fig.  1 ;  the  long  tendon  sur- 
rounds the  bone  and  at  the  same  time  is  slightly 
turned  on  edge. 

The  correct  mode  of  reduction  is  represented  in 
Fig.  2.  First  hyperextension  must  be  effected,  as 
indicated  in  Fig.  2,  by  finger  I.  pressing  in  the  direc- 
tion of  the  arrow.  The  thumb  in  this  position  then 
is  pushed  forward  along  the  base  of  the  first  pha- 
lanx, as  it  were  crowded  beyond  the  head  of  the 
metacarpal,  as  shown  by  Finger  II.  pushing  in  the 
direction  of  the  arrow.  This  manipulation  succeeds 
in  reducing  simple  cases  if  it  is  performed  with  the 
necessary  skill.  It  fails  only  when  special  conditions 
result  from  an  interposition  which  will  become  ap- 
parent and  be  overcome  by  making  a  longitudinal 
incision  in  the  direction  of  the  projecting  metacarpal 
head  and  separating  the  tissues  until  the  obstruction 
is  reached. 


51 


IV.     Fractures  and  Liuxations  of  the  Upper 

Extremity. 

Injuries  of  the  upper  extremity  may  have  a  direct 
or  an  indirect  causation.  While  a  direct  force  pro- 
duces certain  lesions  whose  presence  can  frequently 
be  inferred  from  a  knowledge  of  the  cause,  indirect 
injuries  of  different  forms  maj'  be  due  to  one  and  the 
same  cause.  Thus  a  fall  on  the  hand  may  produce  a 
typical  fracture  at  the  lower  end  of  the  radius,  an 
injury  in  the  elbow-joint,  at  the  upper  end  of  the 
humerus,  or  in  the  shoulder-joint,  and  in  children 
frequently  enough  a  fracture  of  the  clavicle. 

1.    CLAVICLE. 

Fractures  of  the  clavicle  may  affect  any  part  of  the 
bone,  but  are  most  frequent  about  the  middle.  The 
symptoms  of  this  typical  fracture  of  the  clavicle,  in 
the  large  majority  of  cases  of  an  indirect  origin,  are 
as  a  rule  characteristic.  The  displacement  of  the 
fragments  is  due  both  to  muscular  traction  and  to  the 
weight  of  the  arm.  The  sternal  fragment  is  in- 
fluenced by  the  sterno-cleido-mastoid  and  is  usually 
displaced  slightly  upward.  Owing  to  the  traction  of 
the  powerful  muscles  passing  from  the  thorax  to  the 
arm,  the  external  fragment  with  the  whole  arm  is  ap- 
proximated to  the  thorax ;  for  under  normal  conditions 
the  clavicle  acts  as  it  were  as  a  cross-beam  which 

49 


50  FRACTURES   AND    LUXATIONS. 

keeps  the  region  of  the  shoulder  away  from  the 
thorax.  As  a  consequence  of  these  relations,  in 
typical  clavicular  fracture,  the  arm  sinks  down ;  it  is 
lower  than  on  the  healthy  side.  Secondly,  the  arm  as 
a  whole  is  approximated  to  the  thorax  and  conse- 
quently the  axilla  is  obliterated.  Thirdl}^  the  arm 
is  displaced  forward  and  inward,  a  kind  of  inward 
rotation,  obviously  the  result  of  the  predominant  trac- 
tion of  the  thoracic  muscles. 

Tiie  diagnosis  of  clavicular  fracture  therefore  is 
very  simple,  especially  because  the  displaced  frag- 
ments can  be  felt  directly  on  this  superficial  bone, 
and  the  pain  and  the  functional  disturbance  point  to 
the  seat  of  the  injury. 

The  treatment  of  these  typical  clavicular  fractures 
requires  in  the  first  place  a  very  accurate  replacement, 
and  then  a  dressing  which  will  constantly  counteract 
the  causes  of  the  displacement.  As  is  well  known, 
it  was  formerly  considered  a  rare  thing  and  an  almost 
impossible  task  to  cure  such  a  fracture  w^ithout  dis- 
placement of  the  fragments.  Our  present  auxilia- 
ries enable  us  to  effect  recovery  almost  invariably  in 
good  position,  even  in  severe  cases  of  this  nature. 

During  the  replacement  and  the  application  of  the 
dressing  (Fig.  2)  it  is  advisable  to  have  an  assistant 
stand  behind  the  seated  patient  and  draw  both  shoul- 
ders of  the  latter  vigorously  backward.  For  a  dress- 
ing the  strips  of  adhesive  plaster  recommended  by 
Sayre  are  suitable.  Three  such  strips  are  required, 
two  of  which  serve  for  correcting  the  displacement 
mentioned  above.  The  first  strip  corrects  the  inward 
rotation  of  the  arm  or  shoulder  region ;  it  passes  at  the 
upper  end  of  the  arm  from  within  outward  over  the 


THE    UPPER    EXTREMITY. 


51 


shoulder  to  the  back.  The  second  strip  lifts  the  de- 
pressed arm  by  passing  from  the  elbow  region  to  the 
healthy  shoulder.  The  third  strip  acts  merely  as  a 
mitella  parva;  it  raises  the  hand  and  passes  to«the 
injured  shoulder,  while  it  at  the  same  time  exerts  a 


Fig.  2. 

gentle  pressure  from  in  front  and  above  upon  the  frag- 
ments. One  indication  which  is  not  quite  fulfilled  by 
this  dressing  is  the  restoration  of  the  axillary  cavity. 
This  indication  is  met  by  placing  into  the  axilla  a 
well-fitting  cushion  of  some  soft  material  (cotton  or 
wood  wool  wrapped  in  mull)  and  retaining  it  there. 


52  FRArXURES    AND    LUXATIONS. 

The  effect  of  this  dressing  is  strengthened  by  a  few 
turns  of  a  roller  bandage.  In  applj'ing  this,  occasion- 
ally a  small  pad  may  be  so  fixed  over  the  fracture  as 
to  exert  slight  pressure  from  above  upon  the  sternal 
fragment.  In  summer  it  is  desirable  to  dust  the 
parts  to  be  covered  by  the  dressing,  especially  the 
axilla,  with  some  toilet  powder. 

In  order  to  intensify  the  effect  of  these  strips  of 
adhesive  i:>laster  it  might  be  useful  to  insert  pieces  of 
rubber  bandage  in  the  strips  and  place  them  at  such 
tension  as  to  exert  continuous  elastic  pressure  which 
would  counteract  a  tendenc}"  to  a  recurrence  of  the 
displacement.  The  tension  could  be  regulated  by  an 
appropriate  application  of  a  rubber  tube.  With 
proper  supervision  and  if  the  surgeon  possesses  the 
necessary  technical  skill  he  will  succeed  in  securing 
satisfactor}'  results. 

Incidental  injuries  may  involve  the  brachial  plexus 
and  more  rarely  the  large  vessels.  A  portion  of  the 
plexus  may  also  be  injured  secondarily  by  pressure  of 
the  callus  from  which  it  cannot  escape  owing  to  its 
position  on  the  first  rib. 

Fracture  in  the  median  and  lateral  third  of  the 
clavicle  as  a  rule  is  not  associated  with  displacement, 
excepting  fracture  at  the  extreme  acromial  end,  in 
w^hich  the  lateral  fragment  often  is  almost  upright. 
Cases  of  separation  of  a  splinter  and  infraction  are 
to  be  treated  on  the  above  principles. 

Luxations  of  the  Clavicle. 

a.  Sternal  luxation,  i.e.,  dislocation  of  the  sternal 
end  of  the  clavicle,  occurs  in  different  varieties, 
namel}' : 


THE    UPPER   EXTREMITY. 


53 


Forward  (presternal). 

Upward  (suprasternal.)  These  occur  only  indi- 
rectly through  leverage  when  the  first  rib  serves  as  a 
fulcrum,  or  through  an  extraneous  force  according  to 


Fig.  3. 

the  position  of  the  clavicle,  backward  or  downward. 
As  regards  the  former  variety,  secondary  displace- 
ment may  likewise  be  of  importance. 

Backward  (retrosternal),  very  rare,  through  direct 
force. 


54  FRACTURES   AND   LUXATIONS. 

The  diagnosis  is  always  easy  because  all  parts  are 
accessible  to  palj^ation.  In  backward  luxation  respi- 
ration and  deglutition  may  be  interfered  with  through 
pressure  on  the  trachea  and  oesophagus.  In  differen- 
tiating fractures  near  the  articular  end  use  is  made  of 
palpation  of  the  normal  rounded  bony  prominences 
and  mensuration  of  the  length  of  the  clavicle. 

Treatment. — Replacement  is  generally  easy;  re- 
tention, that  is,  maintenance  of  the  correct  position, 
difficult.  The  requirements  are  exact  dressings,  with 
direct  pressure  on  the  replaced  articular  extremity, 
sometimes  those  having  an  elastic  effect  (see  Treat- 
ment of  Clavicular  Fractures),  occasionally  fixation 
by  means  of  percutaneous  suture. 

h.  Acromial  luxation,  namely  : 

Upward  (supra-acromial) . 

Downward  (infra-acromial),  the  latter  very  rare. 

The  former  often  results  from  direct  force  acting 
upon  the  acromion  when  the  clavicle  is  fixed ;  it  is 
therefore  really  a  downward  luxation  of  the  scapula. 
This  luxation  is  complete  when  the  dislocation  is  ex- 
tensive owing  to  rupture  of  the  coraco-clavicular 
ligament. 

The  diagnosis  is  easy,  since  exact  palpation  may 
be  made,  but  this  dislocation  is  sometimes  mistaken 
for  a  luxation  of  the  humerus.  (Compare  the  de- 
scription of  Plate  25.) 

Treatment. — Here,  too,  replacement  is  easy  and 
retention  often  very  difficult.  By  turns  of  a  roller 
bandage  the  arm  is  elevated  and  the  clavicle  at  the 
same  time  pressed  down.  Sometimes  an  elastic  band- 
age or  the  percutaneous  suture  of  the  ligaments  will 
be  required  (Baum). 


THE    UPPER   EXTREMITY.  55 


2.    SCAPULA. 

Different  forms  of  fracture  of  the  scapula  occur; 
those  of  the  body  and  the  spine  of  the  scapula  are 
direct  and  are  often  associated  with  several  lines  of 
fracture  and  fissures,  though  the  fragments  are  but 
slightly  displaced.  Crepitation  and  abnormal  mobil- 
ity can  often  be  felt,  especially  if  the  arm  be  in  a 
suitable  jDositi on.     Treatment:  fixation  of  the  arm. 

Fractures  at  the  neck  of  the  scapula  are  rare,  but 
are  most  liable  to  occur  at  the  surgical  neck,  that  is 
to  say,  the  coracoid  process  remains  attached  to  the 
articular  portion  and  the  line  of  fracture  extends 
downward  from  the  notch  (see  Plate  24) .  This  frac- 
ture of  the  neck  of  the  scapula  is  important  in  differ- 
ential diagnosis,  since  it  may  be  mistaken  for  sub- 
coracoid  luxation  of  the  humerus.  The  symptoms  of 
this  fracture  are  descent  of  the  arm,  which  may  even 
be  slightly  abducted,  and  marked  prominence  of  the 
acromion ;  the  deformity  disappears  with  crepitation 
when  the  arm.  is  elevated,  but  returns  immediately 
when  the  arm  is  released;  sometimes  the  edge  of  the 
fractured  surface  can  be  felt  from  the  axilla.  Union 
generally  results  from  the  employment  of  a  dressing 
which  puts  the  arm  and  scapula  at  rest  and  fixes  the 
arm  in  its  correct  position  by  the  use  of  an  axillary 
pad,  in  a  way  similar  to  Saj^re's  adhesive-plaster 
dressing  in  clavicular  fracture.  The  arm  must  be 
permanently  elevated  and  kept  slightly  outward  and 
backward. 

Separation  at  the  margin  of  the  socket,  especially 
of  the  inferior  portion,  is  rare  and  can  be  recognized 


56  FRACTURES   AND    LrXATIOis^S. 

as  an  intra-articular  injury  only  in  certain  positions 
of  the  arm  at  the  shoulder-joint.  There  is  some  de- 
scent of  the  head  of  the  humerus  when  the  arm  is 
kept  in  a  lateral  horizontal  position,  and  at  times 
crepitation  when  the  head  of  the  humerus  is  moved 
from  before  backward.  Isolated  fractures  of  the 
coracoid  process,  by  direct  force,  are  exceedingly  rare; 
those  of  the  acromion  are  more  frequent  and  are 
diagnosticated  by  direct  palpation  and  the  demonstra- 
tion of  abnormal  mobilit}'  and  crepitation ;  sometimes 
the  fissure  may  be  felt  when  the  arm  is  vigorously 
drawn  across  the  body.  Union  results  when  the  arm 
is  slightly  elevated  and  placed  at  rest. 

3.    SHOULDER-JOINT. 

Luxations  at  the  shoulder-joint  are  among  the  most 
important  and  frequent  injuries.  Their  diagnosis  is 
usually  not  difficult,  and  still  some  cases  pass  un- 
recognized. On  the  normal  shoulder  we  feel  the 
acromion  extending  from  the  spine  of  the  scapula,  its 
connection  with  the  clavicle,  below  it  the  coracoid 
process,  then  the  head  of  the  humerus  under  the  del- 
toid muscle  usuall}'  so  distinctly  that  on  its  rotation 
we  can  even  palpate  the  tuberosity  and  the  intertuber- 
cular  sulcus,  and  from  the  axilla  the  head  of  the  hu- 
merus and  the  margin  of  the  glenoid  fossa.  As  is 
well  known,  this  very  movable  joint  is  kept  in  con- 
tact, not  by  the  capsule  and  ligaments,  but  b}^  the 
muscles  and  atmospheric  pressure.  In  paralj'sis  of 
the  deltoid  muscle  the  head  of  the  humerus  always 
sinks  slightly,  and  there  are  cases  of  essential  paraly- 
sis in  children  in  which  the  descent  of  the  head  of  the 


THE    UPPER    EXTREMITY.  57 

humerus  is  at  once  perceptible  through  the  thin  over- 
lying soft  parts. 

a.  Forward  luxation  of  the  humerus  (preglenoid, 
subcoracoid,  or  subclavicular,  according  to  the  degree 
of  dislocation  of  the  head  under  the  coracoid  process 
or  the  clavicle)  is  the  most  frequent  luxation  at  the 
shoulder-joint.  The  artificial  production  of  this  dis- 
location in  the  cadaver  resting  on  its  back  is  usually 
easy  when  the  arm  is  highly  elevated  laterally  or 
abducted  and  gradually  but  vigorously  pressed  back- 
v^ard.  In  this  way  the  capsule  is  greatly  stretched 
antero-internally  by  the  advancing  head,  it  gives 
way  (this  is  its  thinnest  portion),  the  head  passes 
through  the  lacerated  capsule  forward  under  the 
coracoid  process,  and  the  luxation  is  complete;  as 
soon  as  the  arm  is  placed  in  a  more  normal  position 
all  the  objective  signs  excepting  the  effusion  of  blood 
are  present. 

During  life  subcoracoid  luxation  sometimes  arises 
directly  from  a  postero-lateral  blow  against  the  hu- 
merus, more  frequently  indirectly  by  a  fall  on  the 
side  while  the  arm  is  raised  and  abducted,  or  else  by 
a  fall  upon  the  extended  hand  or  the  elbow,  especially 
when  the  arm  is  directed  backward.  The  luxation 
has  also  been  observed  as  a  result  of  violent  move- 
ments of  the  arm  (hurling,  flinging),  that  is,  through 
muscular  action. 

In  the  indirect  occurrence  of  this  luxation,  by  ex- 
cessive abduction  the  arm  at  last  comes  into  lateral 
contact  with  the  scapula ;  the  region  of  the  tuberosity 
and  the  surgical  neck  of  the  humerus  press  against 
the  upper  margin  of  the  glenoid  fossa  if  the  force 
continues  to  act ;  the  latter  point  forms  a  fulcrum  and 


58  FRACTURES  AND   LUXATIONS. 

the  short  lever,  i.e.^  the  head  of  the  humerus,  is  lifted 
out  of  its  normal  position  and  connections.  The  lux- 
ation when  thus  effected  is  as  a  rule  more  or  less 
downward,  infraglenoid ;  but  by  a  secondary  dis- 
placement of  the  humerus  (muscular  traction)  the 
subcoracoid  variety  results. 

The  symptoms  of  the  typical  subcoracoid  luxation 
are  quite  characteristic.  They  are  all  based  on  the 
fact  that  the  head  of  the  humerus  is  absent  from  its 
normal  position  and  present  in  an  abnormal  location. 
The  examination  alwa3'S  begins  with  inspection, 
which  alone  often  suffices  for  the  diagnosis,  so  that 
palpation  is  needed  merely  to  place  it  beyond  doubt. 
It  is  best  that  the  patient  be  seated  free  on  a  chair, 
his  trunk  being  bare,  so  that  the  i^hj'sician  sitting 
opposite  can  easily  inspect  and  compare  both  sides. 

The  rounded  outline  of  the  shoulder  has  dis- 
ajipeared  and  the  acromion  forms  an  angular  projec- 
tion. The  normal  round  outline  of  the  shoulder  is 
formed  by  the  head  of  the  humerus  and  the  deltoid 
muscle ;  if  the  latter  is  much  atrophied  the  acromion 
is  prominent;  if  the  head  of  the  humerus  is  absent 
from  its  normal  position  the  acromion  presents  an 
angular  projection  even  when  the  deltoid  is  well  de- 
veloped and  in  spite  of  the  effusion  of  blood  which 
exists.  That  this  prominence  is  of  the  acromion  is 
easily  determined  b}^  following  the  spine  of  the  scap- 
ula, which  terminates  in  the  acromion,  from  the 
back. 

In  the  region  below  the  coracoid  process  an  abnor- 
mal prominence  is  visible  and  palpable;  it  is  felt  par- 
ticularly if  the  humerus  is  slightl}'  turned  forward 
and  backward,   when  it  becomes  evident  that  the 


THE    UPPER   EXTREMITY.  59 

prominence  is  part  of  the  arm,  and  its  rounded  form 
proves  it  to  be  the  head  of  the  humerus. 

The  arm  is  in  a  position  of  elastic  abduction,  that 
is  to  sa}',  it  can  be  ad  ducted  into  contact  with  the 
thorax  by  moderate  force,  but  on  being  released  it 
immediately  springs  back  into  the  abducted  position. 
This  symptom  is  caused  by  the  tension  of  some  liga- 
ments (the  coraco-humeral)  and  the  muscles  inserted 
at  the  tuberosity. 

The  longitudinal  axis  of  the  arm  passes  to  the  cora- 
coid  process  or  under  the  clavicle,  instead  of  under  the 
acromion,  its  normal  direction.  This  fact  is  ascer- 
tained especially  by  comparison  with  the  healthy  side. 

The  external  contour  of  the  arm  forms  an  angle 
open  outward,  while  on  the  healthy  arm  it  is  nearly 
straight.  This  change  is  the  result  of  the  abducted 
position  of  the  arm  to  which  the  lower  half  of  this 
outline  corresponds,  and  of  the  tension  of  the  fibres 
of  the  deltoid  between  the  acromion  and  the  arm, 
which  fibres  form  the  upper  portion  of  this  angular 
contour. 

The  humerus  seems  to  be  elongated  and  the  dis- 
tance from  the  acromion  to  a  point  at  the  elbow  (for 
instance,  the  external  condyle  of  the  humerus)  is  act- 
ually very  often  lengthened;  it  certainly  is  never 
shortened.  This  is  manifest  also  on  inspecting  the 
patient  from  behind.  The  explanation  of  this  elon- 
gation is  furnished  at  once  by  producing  this  luxa- 
tion in  the  skeleton :  the  head  of  the  humerus  is  really 
somewhat  below  its  normal  position  in  the  socket.  It 
is  self-evident  that  during  mensuration  and  inspec- 
tion the  two  arms  should  be  exactly  symmetrical  in 
position. 


60  FRACTURES   AND   LUXATIONS. 

At  the  same  time  the  head  of  the  humerus  can  be 
felt  more  or  less  distinctly  from  the  axilla  in  its  false 
position ;  passive  movements  are  painful  and  limited, 
and  active  movements  are  still  more  restricted. 

Among  incidental  injuries  to  be  observed  may  be 
mentioned  separation  of  splinters  about  the  major  tu- 
berosity, rarely  lesions  of  the  vessels,  but  more  often 
nerve  lesions.  In  this  luxation  the  nerves  are  always 
tensely  stretched,  sometimes  they  are  bruised  during 
the  occurrence  of  the  luxation  by  the  head  of  the  hu- 
merus or  compressed  between  the  latter  and  the 
thorax.  The  axillary  nerve  is  particularly  liable  to 
be  injured,  and  therefore  it  is  desirable  to  test  the 
deltoid  muscle  supplied  by  it,  immediately  after  re- 
placement lest  an  error  be  made  in  the  prognosis. 

The  diagnosis  of  this  luxation,  therefore,  is  not 
difficult  as  a  rule;  should  any  doubt  remain  it  will  be 
removed  by  examination  under  anaesthesia.  In  the 
differential  diagnosis  the  following  conditions  are  to 
be  considered : 

Contusion  of  the  shoulder  and  distorsion  of  the 
shoulder-joint  present  no  dislocation. 

Supra-acromial  luxation  of  the  clavicle.  In  this 
accident  the  angular  projection  is  caused  by  the  acro- 
mial end  of  the  clavicle  and  not  by  the  acromion. 
The  arm  is  not  abducted. 

Fracture  of  the  neck  of  the  scapula.  The  acromion 
projects,  the  head  of  the  humerus  is  lowered  and 
slightly  displaced  forward  and  inward,  but  the  dislo- 
cation disappears  when  the  arm  is  simply  pushed  up, 
during  which  act  crepitation  is  usually  felt. 

Paralysis  of  the  deltoid  muscle  is  followed  by  de- 
scent of  the  arm,  but  this  displacement  disappears  at 


THE    UPPER    EXTPtEMITY.  61 

once  when  the  arm  is  pushed  up.  Moreover,  the  arm 
is  not  abducted. 

Fracture  of  the  acromion  with  marked  displace- 
ment of  the  fragments.  In  this  injury  the  anatomi- 
cal relation  bet^veen  the  acromion  and  the  head  of  the 
humerus  remains  unchanged. 

Fracture  of  the  neck  of  the  humerus.  The  round- 
ness of  the  shoulder  is  preserved  even  when  the  frag- 
ment of  the  shaft  is  displaced  inward;  the  arm  is  not 
elastically  abducted  and  is  never  lengthened ;  on  the 
contrary  it  is  nearly  always  shortened. 

Treatment. — An  early  reduction  should  unques- 
tionably be  attempted.  By  the  exercise  of  some  skill 
the  reduction  may  be  effected  without  resorting  to 
anaesthesia;  often  the  head  is  easily  replaced  while  the 
surgeon  pretends  to  make  merely  an  exact  examina- 
tion. In  other  cases  the  attempts  fail,  when  anaes- 
thesia should  be  at  once  induced. 

Of  the  many  methods  of  reduction  which  have  been 
devised  and  performed  in  the  course  of  time  onlj^  the 
following  need  be  recommended  here : 

1.  Extension  by  an  assistant  of  the  slightly  ab- 
ducted arm  of  the  recumbent  patient,  counter-exten- 
sion being  effected  by  means  of  a  broad  cloth  wound 
about  the  thorax.  The  surgeon  at  the  same  time 
performs  manipulations,  especially  direct  pressure 
upon  the  head  toward  the  socket.  (Cooper's  well- 
known  method :  Traction  upon  the  arm  in  the  longi- 
tudinal direction  of  the  body,  with  simultaneous 
pressure  of  the  foot  [without  shoe]  in  the  axilla,  thus 
exerting  direct  pressure  upon  the  head.) 

2.  Kocher's  method  of  rotation.  This  consists  of 
several  steps  or  positions  which  must  be  exactly  fol- 


62  FRACTUKES   AND   LUXATIONS. 

lowed  (compare  Plate  22) .  The  order  of  the  steps  is, 
adduction  of  the  arm  until  it  touches  the  trunk ;  out- 
ward rotation  until  the  flexed  forearm  is  about  in  the 
frontal  plane  (to  be  done  with  great  care  lest  fracture 
result) ;  forward  elevation  of  the  arm ;  and  finally 
inward  rotation. 

It  is  particularly  by  this  method  that  reduction 
succeeds  not  rarely  without  anaesthesia  and  in  the 
most  gentle  manner.  The  adduction  causes  tension 
of  the  upper  wall  of  the  capsule  and  fixation  of  the 
head  at  the  margin  of  the  capsule,  so  that  during  ro- 
tation it  turns  about  the  latter  and  not  on  its  axis. 
The  elevation  relaxes  the  coraco-humeral  ligament. 

The  success  of  the  reduction  is  indicated  by  a  more 
or  less  distinct  snap  of  the  head  and  by  the  restora- 
tion of  the  normal  shape  and  the  regained  mobility. 

In  the  after-treatment  the  arm  is  best  so  fixed  by 
cloths,  bandages,  or  strips  of  adhesive  plaster  that 
the  hand  of  the  injured  side  rests  on  the  healthy 
shoulder.  After  a  week  passive  movements  are  be- 
gun, which  are  followed  later  on  by  active  move- 
m.ents.  The  whole  diu-ation  of  the  treatment  until 
the  patient  can  return  to  work  is  about  four  to  five 
weeks. 

If  reduction  fails,  other  attempts  must  be  made 
under  profound  anaesthesia,  the  laceration  of.  the  cap- 
sule having  been  enlarged  by  extensive  movements. 
If  these  attempts  fail,  even  with  the  aid  of  other 
physicians,  operative  reduction  must  undoubtedly 
be  performed  in  order  to  force  restitution  as  soon  as 
possible.  By  using  the  incision  for  resection,  from 
the  coracoid  process  downward,  success  will  be  easily 
obtained. 


THE    UPPER    EXTREMITY.  63 

If  the  reduction  is  not  effected,  the  result  will  be  as 
a  rule  the  most  undesirable  condition  of  an  old  luxa- 
tion. But  rarely  a  nearthrosis  with  some  mobility  is 
formed ;  generally  the  region  of  the  shoulder  remains 
painful  and  the  movements  are  reduced  to  a  mini- 
mum. Even  in  such  old  cases  improvement  may  be 
secured  by  arthrotomy  and  reduction  or  by  resection. 

In  rare  cases  a  state  of  habitual  luxation  develops. 

Modifications  and  Complications  of  Pr^gle- 
NOiD   Luxation. 

When  the  head  of  the  humerus  leaves  the  socket 
directly  forward,  it  lies  between  the  scapula  and  the 
subscapular  muscle,  often  so  close  to  the  socket  that 
the  articular  surface  of  the  head  still  touches  the 
margin  of  the  glenoid  fossa.  In  such  cases,  which 
mainly  result  from  direct  force,  the  bones  abrade 
each  other  at  their  points  of  contact  within  a  few 
weeks.  In  old  cases  of  this  kind  the  abrasion  is  pro- 
nounced, being  in  the  form  of  a  deep  groove  at  the 
head  of  the  humerus,  and  of  an  erosion  of  the  anterior 
half  of  the  glenoid  fossa ;  at  the  same  time,  however, 
we  find  the  well-known  periosteal  proliferations  by 
which  a  kind  of  new  socket  is  formed  for  the  head  in 
its  abnormal  position.  (Compare  Plate  23.)  The 
reduction  of  such  cases  is  usually  very  difficult,  and 
often  impossible  without  arthrotomy. 

Supracoracoid  luxation  is  extremely  rare  and  al- 
ways associated  with  fracture  of  the  coracoid  process. 

a.  Luxation  combined  with  fracture  of  the  neck  of 
the  humerus  is  a  serious  injury.  When  reduction 
by  traction  aided  by  direct  manipulation  fails,  ar- 


04  FRACTURES   AND   LUXATIONS. 

throtomy  must  be  performed  and  reduction  forced. 
Formerly  it  was  advised  to  secure  a  false  joint  at  the 
seat  of  the  fracture,  leaving  the  head  in  the  luxated 
position. 

b.  Downward  (infraglenoid  or  axillary)  luxation 
of  the  humerus.  In  this  dislocation  the  bead  is  at 
the  lower  margin  of  the  glenoid  fossa  and  can  be  at 
once  felt  from  the  axilla.  When  the  arm  is  elevated 
horizontally  the  appearance  is  quite  characteristic,  a 
marked  bayonet-like  depression  of  the  line  of  the 
shoulder  being  visible.  The  acromion  is  prominent, 
the  articular  cavity  is  empt}',  and  the  function  is  dis- 
turbed. Sometimes  the  arm  is  raised  (luxatio  erecta) 
or  fixed  horizontally.  Reduction  succeeds  by  trac- 
tion on  the  arm  and  direct  pressure  against  the  head 
from  the  axilla  (the  thumbs  if  need  be  pressed  against 
the  acromion). 

c.  Backward  (retroglenoid,  subacromial,  infraspi- 
nata)  luxation  of  the  humerus  is  very  rare  and  usu- 
ally due  to  direct  force.  The  head  is  easily  seen  and 
felt  in  its  abnormal  position;  the  coracoid  process 
projects  markedly.  Reduction  is  effected  by  traction 
upon  the  arm  with  adduction  and  direct  pressure. 

4.    ARM. 

A.    Fractures  at  the  Upper,  End. 

a.  Fracture  of  the  anatomical  neck  (Plate  2S,  Fig. 
'd)  is  very  rare,  especially  in  a  pure  form.  Should 
only  that  portion  of  the  head  which  is  covered  with 
cartilage  break  off,  a  strictly  intracapsular  fracture, 
the  vitality  of  the  fragment  would  be  doubtful;  it 
would  act  like  separate  osseo-cartilaginous  fragments. 


THE  Upper  extremity.  65 

for  instance,  in  the  knee-joint.  Hence  as  a  rule  this 
fracture  is  not  purely  intracapsular,  but  the  fragment 
is  generally  attached  to  and  nourished  by  portions  of 
the  capsule. 

The  cause  is  usually  a  direct  force.  The  head  may 
be  impacted  between  the  tuberosities,  or  the  upper 
diaphyseal  end  in  the  cancellous  structure  of  the  head ; 
the  displacement  may  be  very  slight  or  very  great, 
the  fragment  of  the  shaft  being  shifted  forward,  in- 
ward, and  upward ;  complete  inversion  of  the  fragment 
of  the  head  has  also  been  observed,  the  cartilaginous 
surface  being  turned  toward  the  fractured  surface  of 
the  shaft  of  the  humerus. 

The  symptoms  are  those  of  an  intra-articular  in- 
jury. The  diagnosis  is  possible  only  by  careful 
examination  under  anaesthesia,  with  deep  palpation 
of  the  bony  points  and  the  demonstration  of  abnor- 
mal mobility  and  crepitation  of  the  upper  end.  of  the 
humerus. 

Treatment. — Rest  in  bed  with  extension  of  the 
arm  downward  and  outward  by  weights,  a  pillow 
being  inserted  in  the  axilla  or  additional  traction  em- 
ployed, acting  laterally  at  the  upper  end  of  the  hu- 
merus.    Passive  movements  should  be  begun  early. 

h.  Fracture  at  the  surgical  neck  (Plate  28,  Fig.  3) 
is  a  frequent  injury.  The  line  of  fracture  lies  below 
the  tuberosity  or  penetrates  into  it.  The  upper  frag- 
ment therefore  may  still  be  under  the  influence  of  the 
muscles  inserted  at  the  tuberosity.  The  fracture  is 
usually  due  to  a  fall  upon  the  shoulder,  in  persons  of 
somewhat  advanced  age;  sometimes  it  results  from  a 
fall  upon  the  hand  or  the  elbow.  The  fragments 
may  be  fixed  by  impaction;  compare  the  specimen  of 


66  FRACTURES   AXD    LUXATIONS. 

a  fracture  by  compression,  Plate  3,  Fig.  2.  Tlie 
fragments  may  also  unite  with  marked  displacement, 
the  upper  end  of  the  shaft  of  the  humerus  being  fre- 
quently shifted  forward,  inward,  and  upward. 

Symj^toms. — On  palpating  the  lateral  contour  of 
the  shoulder  we  perceive  under  the  acromion  the 
spherical  head  of  the  humerus  in  its  normal  position 
and  the  injured  arm  adjoins  the  thorax  (is  not  in 
elastic  abduction) ;  in  many  cases  the  arm  is  also 
shortened  (which  will  distinguish  it  from  the  sub- 
coracoid  luxation).  Usually  abnormal  mobility  and 
crepitation  (especially  on  rotating  the  arm)  are  also 
present;  sometimes  the  before-mentioned  displace- 
ment of  the  end  of  the  shaft  forward,  inward,  and 
upward  can  be  demonstrated.  In  the  latter  case 
there  is  some  similarity  to  subcoracoid  luxation,  but 
the  shortening  and  the  other  symptoms  enumerated 
above  serve  for  the  differentiation.  When  the  frag- 
ments are  impacted  the  diagnosis  may  become  more 
difficult,  but  exclusion  of  a  luxation  will  always  be 
possible.  With  reference  to  a  fracture  associated 
with  luxation,  vide  sujova  under  Luxation. 

T/'eatnient. — Reposition  is  to  be  carefully  effected 
when  a  marked  displacement  is  present.  In  the  fur- 
ther treatment  splint  dressings  for  fixing  the  whole 
arm  with  the  shoulder  region  as  far  as  the  neck,  to- 
gether with  the  use  of  an  axillar}^  cushion,  are  suffi- 
cient unless  there  is  a  tendency  to  a  displacement  of 
the  fragments.  In  that  event  it  is  better  not  to  rely 
on  ambulator}'  treatment  of  this  serious  injury  which 
ultimately  may  become  incurable  through  functional 
disturbance;  instead,  we  may  employ  rest  in  bed  and 
permanent  extension  by  weight  and  pulley  in  the  Ion- 


THE    UPPER    EXTREMITY.  67 

gitndinal  direction  of  the  arm,  together  with  an 
axillary  cushion  or,  better,  a  second  extension  appa- 
ratus acting  upon  the  upper  end  of  the  shaft.  Dur- 
ing this  treatment  the  region  of  the  shoulder  which 
is  bare  is  open  to  inspection,  massage  can  be  em- 
ployed, and  (the  weights  being  temporarily  removed) 
we  may  begin  in  the  first  few  days  with  careful  pas- 
sive movements.  Otherwise  all  that  has  been  said 
above  in  the  general  part  about  the  treatment  of 
fractures  involving  the  joints  applies  to  this  injury. 

c.  Fracture  of  the  tuberosity,  especially  the  major 
one,  during  the  occurrence  of  subcoracoid  luxation, 
that  is,  always  combined  with  the  latter  (as  a  frac- 
ture by  traction).  The  lesser  tuberosity  is  even  less 
apt  to  break.  The  symptoms  of  an  isolated  fracture 
of  these  bony  processes  are  not  pronounced ;  we  find 
the  signs  of  a  contusion  and  sometimes  are  able  to 
feel  the  mobility  of  the  fractured  osseous  promi- 
nence. This  fracture  may  also  occur  during  the  re- 
duction of  old  luxations  of  the  shoulder. 

Transtubercular  fracture  means  a  transverse  frac- 
ture of  the  humerus  at  the  level  of  the  tuberosity; 
compare  the  remarks  upon  fracture  of  the  surgical 
neck. 

d.  Traumatic  separation  of  the  epiphysis  at  the 
upper  end  of  the  humerus  (Plates  27  and  28).  This 
injury  is  of  great  practical  importance  on  account  of 
its  relative  frequency.  Of  course  it  is  possible  only 
before  the  ossification  of  the  so-called  epiphj^seal  car- 
tilage (better,  intermediary  cartilage),  that  is  to  say, 
in  young  persons,  and  is  due  to  a  fall  upon  the 
shoulder  or  the  arm. 

In  order  to  understand  the  lesion  it  is  necessary  to 


68  FRACTURES   AND    LUXATIONS. 

know  the  anatomical  details  of  the  epiphyseal  line; 
compare  the  explanation  of  Plate  28,  Fig.  1 . 

The  symptoms  are  often  quite  characteristic;  they 
point  to  a  se^Daration  of  bone,  as  in  fracture  at  the  sur- 
gical neck.  When  the  displacement  is  moderate  it 
may  sometimes  be  possible  to  demonstrate  under 
anesthesia  abnormal  mobility  and  crepitation,  but 
the  latter  is  softer  than  the  ordinary — cartilage  crep- 
itation. Not  rarely,  however,  the  displacement  is 
considerable,  the  diaphyseal  end  being  shifted  for- 
ward and  inward,  at  which  point  it  sometimes  causes 
a  circumscribed,  almost  angular  prominence  which  is 
most  distinct  on  inspection  from  the  side  or  from 
above  (standing  behind  the  patient).  In  rare  cases 
the  displacement  is  such  that  the  fragment  of  the 
shaft  is  almost  luxated  inward  and  upward.  In  that 
case  reposition  even  under  anaesthesia  may  be  very^ 
difficult  or  imj^ossible.  If  it  succeeds  the  further 
steps  are  as  in  fracture  at  the  surgical  neck.  If  it 
fails  reposition  must  be  forced  by  cutting  down  upon 
the  parts  and  separating  the  interposed  soft  structures. 
T  have  the  records  of  several  similar  cases  in  which 
the  fixation  of  the  replaced  fragments  was  effected 
with  excellent  results  by  the  insertion  of  a  long  steel 
needle. 

Exact  reposition  is  necessary  in  order  to  save  these 
young  people  from  deformity  and  functional  disturb- 
ance persisting  through  life.  Moreover,  imperfect 
reposition  after  such  lesions  of  the  epiphj^seal  carti- 
lage is  regularly  follow^ed  by  marked  arrest  of  growth : 
the  humerus  does  not  reach  its  full  length  and  remains 
shorter  than  the  opposite  one  (Plate  37,  Fig.  2). 


THE    UPPER    EXTREMITY.  69 

B.     Fractures  of  the  Diaphysis   of  the  Hu- 
merus (Plate  29). 

Tliese  arise  directly  or  indirectly  and  present  the 
ordinary  symptoms  of  a  fracture  in  a  manner  readily 
demonstrated,  namely,  abnormal  mobility,  crepita- 
tion, various  degrees  of  displacement,  etc.  In  frac- 
tures below  the  attachment  of  the  deltoid  muscle  the 
latter  may  lift;  the  upper  fragment  outward  (disloca- 
tio  ad  axin) .  In  fractures  in  the  region  where  the 
middle  and  lower  thirds  of  the  humerus  join,  the 
radial  nerve  is  liable  to  be  involved,  primarily  by 
lesion  during  the  occurrence  of  the  injur}^  or  second- 
arily by  the  pressure  of  the  callus  in  Avhich  it  is  often 
imbedded  as  in  a  deep  groove.  This  should  be  borne 
in  mind  from  the  start  (paralysis  of  the  extensors  of 
the  hand,  impossibility  of  flexing  the  hand  dorsally), 
lest  a  gross  blunder  be  committed  in  making  the 
prognosis.  Lesions  of  the  vessels  are  of  rarer  occur- 
rence. 

Union  is  normal  under  correct  treatment.  But  the 
occurrence  of  a  pseudarthrosis  is  relatively  more  fre- 
quent after  fractures  of  the  humerus  than  after  those 
of  the  other  bones  of  the  upper  extremity.  This  is 
due  to  a  more  difficult  immobilization  and  to  the  dis- 
placement which  is  sometimes  considerable,  and  in 
addition  may  be  complicated  by  the  interposition  of 
soft  parts  between  the  fractured  ends. 

Treatment. — In  applying  a  circular  dressing  in- 
cluding the  region  of  the  shoulder  and  the  elbow  joint 
the  axilla  must  be  protected  from  injurious  pressure. 
Plaster-of-Paris  or  wire  splints  or  padded  tin  splints 
(if  the  latter  are  used,  a  long  piece  should  cover  the 


70  FRACTURES   AND   LUXATIONS. 

whole  outer  surface  and  a  shorter  piece  the  inner 
surface  of  the  arm)  are  suitable  for  the  dressing. 
Wire  splints  can  be  applied  without  difficulty  in  such 
a  way  as  to  cause  permanent  traction  in  the  longi- 
tudinal direction  of  the  arm.  The  splint  is  bent  ac- 
cordingly and  firmly  fastened  to  the  forearm  flexed  at 
a  right  angle ;  the  upper  end  is  so  curved  as  not  to 
hug  the  shoulder  closel3\  If  then  a  well-padded  loop 
of  bandage  is  placed  in  the  axilla  and  fastened  mod- 
erately tightly  to  the  projecting  end  of  the  splint,  per- 
manent traction  is  exerted  which  can  be  easily 
regulated  by  renewed  tying  of  the  axillary  bandage. 
Occasionally  this  dressing  may  be  employed  also  in 
fractures  at  the  upper  end  and  especially  at  the  lower 
end  of  the  humerus. 

C.    Fractures  at  the  Lower  End  of  the  Hu- 
merus (Plates  30,  31,  32). 

These  fractures  are  frequent  and  of  great  practical 
importance,  for  in  their  gravity,  though  not  always 
in  their  anatomical  character,  they  should  be  looked 
upon  as  articular  fractures.  The  forms  of  these  frac- 
tures are  illustrated  in  the  plates :  Supracondylar  frac- 
ture, T-fracture,  fracture  in.  the  epiphj^seal  line, 
oblique  fractures  through  the  articular  extremity, 
and  isolated  fracture  of  the  internal  and  external 
condyle. 

In  all  these  injuries  very  careful  palpation  is  re- 
quired. A  person  who  is  familiar  with  the  relative 
position  at  the  normal  elbow  of  the  two  condyles  and 
the  olecranon  will  appreciate  the  pathological  con- 
dition in  the  patient,  especially  if  the  healthy  and  the 
injured  side  are  compared. 


THE   UPPER   EXTREMITY. 


71 


Fig,  4. 


72  FRACTURES   AND   LUXATION'S. 

a.  Supracondylar  and  T-Fracture. 

The  former  is  generally  clue  to  a  fall  upon  the  elbow 
or  the  hand  and  is  of  frequent  occurrence  in  children. 
The  T-fracture,  ^.e.,  longitudinal  fracture  of  the 
lower  fragment,  is  caused  by  the  on-crowding  of  the 
olecranon  from  behind  or  the  shaft  of  the  humerus 
from  above.  The  displacement  which  occurs  in  a 
typical  form  by  the  traction  of  the  triceps  and  gives 
rise  to  confusion  with  luxation  of  the  forearm  may 
be  seen  on  Plate  31.  During  the  examination  an 
important  manipulation  is  to  grasp  the  lower  end  of 
the  humerus  transversely  and  firmly  at  its  projecting 
and  easily  found  condyles  and  to  test  whether  it  is 
abnormally  movable.  A  fracture  at  the  lower  end  of 
the  humerus  can  also  be  recognized  by  displacing  the 
forearm  backward  against  the  fixed  arm ;  thus  abnor- 
mal mobility  may  be  ascertained  together  with  crep- 
itation, and  reposition  may  be  effected.  When  the 
shaft  of  the  humerus  has  penetrated  between  the  two 
portions  of  the  lower  fragment  (in  a  T-fracture), 
the  entire  lower  articular  end  is  widened. 

Treatment. — Thorough  reposition,  if  necessary  un- 
der anaesthesia,  followed  by  fixation  with  splints 
(padded  tin  splints  at  the  outer  and  inner  side) ;  the 
elbow  being  extended  or  flexed,  whichever  position 
facilitates  the  retention  of  the  fragments.  In  adults 
it  may  be  necessary  to  apply  an  adhesive-plaster 
dressing  for  permanent  extension  by  weights,  with 
the  aid  of  lateral  traction  slings  or  direct  weighting 
with  sandbags.  In  children  splints  will  do,  but  the 
fact  can  hardly  be  sufficiently  emphasized  that  care- 
ful  reposition    and    frequent   inspection   are   of   the 


THE    UPPER   EXTREMITY.  73 

utmost  importance;  in  the  case  of  such  fractures  in 
children  I  resort  to  anaesthesia  during  the  first  and 
sometimes  during  subsequent  dressings. 

Among  incidental  injuries  lesions  of  the  ulnar 
nerve  are  rarer  than  those  of  the  radial ;  that  such 
complications  require  careful  treatment  is  self-evi- 
dent. 

b.  Fractures  of  the  condyles  may  be  isolated  or 
occur  as  complications,  especially  with  luxations. 
The  diagnosis  is  readily  made  by  the  displacement 
and  mobility  of  the  fragments.  The  treatment  is 
simple :  enforced  rest  by  dressings,  early  movements. 

c.  Oblique  fractures  of  the  articular  extremity 
and  separation  of  the  epiphyses.  These  are  articu- 
lar fractures  of  a  marked  form,  not  rarely  associated 
with  serious  displacement  of  the  forearm  at  the  elbow- 
joint.  Minute  palpation  of  the  several  bony  promi- 
nences and  a  test  of  their  mobility  lead  to  the  forma- 
tion of  a  probable  diagnosis,  which  is  best  made 
positive  under  ansesthesia  if  there  be  great  swell- 
ing and  acute  suffering.  Thus  we  may  frequently 
feel  portions  of  the  fractured  surfaces  and  of  the 
articular  extremity.  With  the  requisite  knowledge 
of  the  normal  structures  and  by  comparison  with  the 
healthy  side  it  will  always  be  possible  to  gain  a  cor- 
rect conception  of  the  nature  of  the  injury. 

The  prognosis  of  these  fractures  unfortunately  is  in 
general  less  favorable  than  that  of  supracondylar 
fractures;  for  a  displacement  of  the  fragments  is 
only  too  liable  to  remain  behind  and  to  give  rise,  at 
this  point,  to  a  limitation  of  the  normal  excursion  of 
mobility  by  irregular  bony  prominences  (osseous 
check).     In  children  and  young  persons,  it  is  true, 


74  FRACTURES  AND   LUXATIONS. 

the  obstruction  may  bo  somewhat  reduced  and  mobil- 
ity improved  in  course  of  time  by  appropriate  exer- 
cises and  the  employment  of  suitable  apparatus  (for 
instance,  Krukenberg's  pendulum  apparatus  for  the 
elbow  joint,  which  I  allow  patients  to  use  at  their 
homes),  but  complete  restoration  never  occurs  in 
these  cases.  Lateral  deviation  of  the  fragments  may 
also  lead  to  displacement;  in  this  way  varus  and  val- 
gus positions  develop  at  the  elbow,  cubitus  varus  and 
valgus.  Two  pronounced  examples  of  valgus  posi- 
tion will  be  found  on  Plate  32. 

Treatment. — What  has  been  said  about  supracon- 
dylar and  T-fractures  applies  pretty  nearly  to  these 
fractures.  They  require  exact  reposition  by  manipu- 
lation of  the  forearm  and  direct  pressure  under  anaes- 
thesia. Then  splint  dressing  in  the  most  appropriate 
position,  sometimes  almost  or  fully  extended,  some- 
times with  flexion  at  the  elbow.  The  flexible  padded 
tin  splints  are  especially  suitable  because  with  every 
change  of  the  dressing — which  should  be  made  every 
three  or  four  days  in  the  flrst  two  weeks,  and  later  on 
every  other  day — they  can  be  at  once  bent  to  corre- 
spond with  the  necessary  change  in  position. 

« 

5.     ELBOW-JOINT. 

For  the  examination  of  luxations  at  the  elbow- joint 
an  accurate  knowledge  of  the  contours  of  the  normal 
joint  is  indispensable.  We  palpate  the  condyles,  the 
olecranon,  their  mutual  relations  in  various  positions 
of  the  joint,  under  the  external  condyle  the  capitulum 
of  the  radius,  which  is  particularly  distinct  in  prona- 
tion and  supination  of  the  forearm ;   in  luxated  posi- 


THE    UPPER   EXTREMITY.  75 

tions  the  articular  ends  can  often  be  felt  very  dis- 
tinctl}^,  e.(/.,  the  capitulum  with  its  central  depression, 
the  eminentia  capitata,  the  trochlea,  the  upper  end  of 
the  ulna.  It  is  part  of  an  exact  examination  that  we 
not  only  believe  we  recognize  one  or  another  bony 
process,  but  we  demonstrate  the  location  of  all  bony 
points  in  their  mutual  relation,  and  know  their  posi- 
tion even  when  a  portion  of  them  cannot  be  directl}' 
palpated.  The  skeleton  of  an  arm  should  be  at  hand 
when  these  injuries  are  studied. 

We  distinguish  the  luxation  of  both  forearm  bones 
and  the  luxation  of  one  of  the  bones. 

a.  Posterior   Luxation   of  the   Forearm   {Plates 

SJf^  So). 

No  dislocation  can  be  more  easily  produced  in  the 
cadaver  than  this,  which,  by  the  way,  is  also  frequent 
during  life.  Hyperextension  causes  a  laceration  of 
the  joint  capsule  on  its  anterior  aspect,  at  the  same 
time  the  olecranon  is  crowded  into  the  posterior 
supratrochlear  fossa;  when  the  bones  are  sufficiently 
forced  apart  and  a  backward  push  is  given  to  the 
forearm  while  the  elbow  is  flexed,  the  luxation  is 
complete.  The  arm  then  is  bent  at  an  obtuse  angle 
in  the  elbow  (on  Plate  34  the  drawing  appears  with  a 
right  angle  owing  to  lack  of  room) .  Further  flexion 
is  opposed  by  the  pressure  of  the  coronoid  process 
against  the  articular  extremity  of  the  humerus. 

In  the  living  patient  this  mechanism  is  unquestion- 
ably the  most  frequent;  but  it  is  said  that  the  luxa- 
tion may  also  result  from  hyperilexion  and  by  forced 
lateral  movement. 

The  symptoms  can  be  readily  understood ;  the  pro- 


76  FRACTURES   AND    LUXATIONS. 

jection  of  the  olecranon  is  immediately  visible.  The 
lower  end  of  the  humerus  ma}"  be  indistinctly^  felt  by 
palpation  under  the  soft  parts  at  the  bend  of  the 
elbow;  onl}^  when  these  parts  are  extensively  lace- 
rated (brachialis  internus  muscle,  nerves,  and  ves- 
sels) can  it  be  felt  under  the  skin,  though  it  may  also 
be  visible  in  a  fissure  of  the  skin  in  compouDd  luxa- 
tions. The  longitudinal  axis  of  the  humerus  does 
not  strike  the  forearm  at  its  end  as  under  normal 
conditions,  but  in  such  a  way  that  a  small  portion  of 
it  protrudes  backward.  The  olecranon  and  the  capi- 
tulum  of  the  radius  are  accessible  to  direct  palpation, 
and  can  be  clearly  followed  when  slight  movements 
of  the  forearm  are  made.  The  condyles  are  at  an 
abnormal  distance  from  the  olecranon;  the  lower  end 
of  the  humerus  admits  of  no  abnormal  movements 
as  in  supracondylar  fracture.  The  humerus  is  not 
shortened.  Forward  traction  of  the  forearm  does 
not  cause  the  dislocation  to  disappear. 

The  diagnosis  may  be  more  difficult  when  compli- 
cating injuries  are  present,  such  as  fracture  of  the 
coronoid  process ;  and  associated  supracondylar  frac- 
ture of  the  humerus  has  also  been  observed,  as  well 
as  fracture  of  the  olecranon.  In  fracture  of  the 
trochlea  the  forearm  with  this  fragment  ma}^  be  dis- 
located backward,  with  luxation  of  the  capitulum  of 
the  radius. 

The  prognosis  may  be  rendered  unfavorable  by 
complications;  otherwise  complete  passive  and  active 
mobility  must  be  secured  after  reduction. 

Treatment. — The  mode  of  reduction  is  illustrated 
on  Plate  35.  As  in  all  hinge  joints  reduction  cannot 
be  affected  by  simple  traction,  no  matter  how  power- 


THE    UPPER    EXTREMITY.  77 

fill.  The  setting  must  proceed  without  any  force,  as 
a  rule  under  anaesthesia.  The  arm  is  first  hyperex- 
tended  in  order  to  free  the  coronoid  process  from  its 
incarceration  in  the  posterior  supratrochlear  fossa. 
Then  moderate  traction  at  the  forearm  brings  it  for- 
ward, while  the  other  hand  grasps  the  affected  elbow 
region  laterally  and  controls  the  position.  The  flex- 
ion now  following  meets  with  no  opposition ;  the  dis- 
location has  disappeared  and  the  normal  contact  of 
the  joint  has  been  restored. 

The  after-treatment  is  typical :  two  weeks'  fixation 
with  repeated  change  of  the  dressings  and  massage; 
then  mobilization. 

h.  Lateral  Luxation  of  the  Forearm  (Plate  33). 

Lateral  luxations  at  the  elbow  joint  likewise  are 
not  rare;  the  outward  variety  is  somewhat  more  fre- 
quent than  the  inward,  and  is  generally  associated 
with  fracture  of  the  condyle.  This  fracture  results 
from  traction  of  the  lateral  ligament  and  affects  the 
condjde  which  is  at  a  greater  distance  from  the  fore- 
arm; that  is  to  say,  outward  luxation  is  complicated 
with  separation  of  the  internal  condyle  and  vice 
versa. 

The  forearm,  however,  is  generally  still  in  contact, 
though  it  be  an  abnormal  one,  with  the  humerus, 
e.g.^  the  ulna  with' the  eminentia  capitata  in  outward 
luxation;  the  capitulum  of  the  radius  projects  free 
supero-externall3\  As  a  rule  the  forearm  is  at  the 
same  time  displaced  backward  so  as  to  present  a  com- 
bination of  lateral  and  backward  luxation.  While 
backward  luxation  may  occur  with  intact  lateral 
ligaments  (although  the  internal  ligament  is  usually 


78  FKACTURES   AND    LUXATIONS. 

lacerated),  lateral  luxation  is  in  most  cases  associated 
with  extensive  laceration  of  ligaments  or,  as  stated 
before,  with  fracture  of  a  condj'le. 

The  form  described  has  also  been  called  incomplete 
luxation,  as  opposed  to  the  complete  dislocation  of  the 
bones,  in  which  no  portion  of  one  articular  surface 
remains  in  contact  with  a  portion  of  the  other. 

Lateral  luxation  always  depends  upon  a  •lateral 
flexion  at  the  elbow.  The  capsule  is  always  exten- 
sively lacerated,  also  from  the  side. 

The  symptoms  of  a  complete  lateral  luxation,  say 
outward,  are  unmistakable  and  need  no  explanation. 

In  incomplete  outward  luxation  (Plate  33)  the 
prominence  of  the  capitulum  of  the  radius  is  clear  to 
the  eye  and  to  the  palpating  finger.  On  the  inner 
side  the  trochlea  can  be  partl}^  felt;  the  internal  con- 
dyle may  be  recognized  as  detached  or  appears  as  a 
marked  prominence.  On  making  gentle  movements 
(examination  under  anaesthesia)  the  whole  condition 
becomes  clear. 

In  incomplete  inward  luxation  the  external  condyle 
projects  markedly  or  is  broken  off;  on  the  inside  the 
ulna  is  prominent  and  its  articular  surface  is  palpa- 
ble; the  capitulum  of  the  radius  is  upon  the  trochlea; 
the  eminentia  capitata  can  be  partly  palpated. 

The  prognosis  depends  upon  the  complications. 

Treatment . — The  reduction  is  effected  in  the  most 
gentle  manner  under  anaesthesia,  by  means  of  hyper- 
extension  and  lateral  pressure  with  the  other  hand, 
followed  by  traction  and  flexion.  When  interposition 
is  present,  extensive  lateral  movements  (hyperexten- 
sion  with  abduction,  etc.)  are  sometimes  useful. 
Should  reduction  fail    the   obstruction   must  be  re- 


THE    UPPER    EXTREMITY.  79 

moved  by  incision  (arthrotomy,  best  lateral) ;  in  this 
way  excellent  results  may  be  obtained. 

c.  Anterior  luxation  of  the  forearm  (the  forearm 
being  dislocated  forward).  This  is  a  very  rare  injury, 
whose  occurrence  was  formerly  denied  unless  associ- 
ated with  fracture  of  the  olecranon.  This  luxation 
may  result  from  a  push  or  fall  upon  the  olecranon 
while  the  forearm  is  in  extreme  flexion  at  the  elbow. 

Symptoms. — The  prominence  of  the  olecranon  is 
absent  in  its  normal  position,  and  the  form  of  the 
lower  end  of  the  humerus  can  be  palpated  on  its  dorsal 
surface.  When  the  outer  surface  of  the  olecranon  is 
still  in  contact  with  the  trochlea  (the  arm  being 
nearly  straight),  the  luxation  is  incomplete;  when 
complete  the  summit  of  the  olecranon  is  situated  be- 
fore the  articular  surface  of  the  lower  end  of  the 
humerus  (the  arm  being  bent  at  an  acute  angle). 
Reduction  by  direct  pressure  under  moderate  exten- 
sion. 

d.  Divergent  luxation  of  the  forearm;  the  ulna 
being  luxated  backward,  the  radius  forward,  so  that 
the  humerus  appears  driven  like  a  wedge  between 
the  ulna  and  radius.  This  injury  is  very  rare.  The 
several  bony  parts  can  be  directly  palpated  in  their 
abnormal  position.  During  reduction  every  bone  is 
to  be  treated  by  itself;  the  ulna  by  hyperextension 
and  traction,  then  the  radius  by  direct  pressure. 

e.  Isolated  luxation  of  the  uhia,  observed  very 
rarely,  results  from  a  fall  upon  the  hand  while  the 
forearm  is  hyperextended  and  pronated.  Sj^mptoms 
like  those  of  a  posterior  luxation  of  the  forearm,  ex- 
cept that  the  capitulum  of  the  radius  is  not  found 
dislocated ;   the  elbow  is  in  varus  position,  the  ulnar 


80  FRACTURES   AXD   LUXATIONS. 

side  of  the  forearm  is  shortened.  Reduction  by 
hyperextension  and  traction. 

/.  Isolated  luxation  of  the  radius,  an  injury 
which  is  less  rare  and  occurs  in  different  forms.  The 
capituhim  may  be  luxated  forward,  backward,  or 
outward ;  the  latter  is  very  rare  in  a  pure  form,  but  is 
more  often  complicated  with  fracture  of  the  ulna  in 
the  upper  third ;  the  capitulum  can  be  felt  at  the  outer 
margin  of  the  external  condyle;  the  radial  side  of  the 
forearm  is  shortened  and  the  elbow  therefore  is  in 
valgus  position.  Reduction  by  direct  pressure,  if 
necessary  by  producing  a  varus  position  at  the  elbow. 

The  backward  form  is  very  rare,  but  easily  recog- 
nized by  palpation  of  the  capitulum  of  the  radius. 
The  elbow  is  half  pronated;  active  extension  and 
supination  are  impossible.  Reduction  by  direct  pres- 
sure during  vigorous  traction  and  varus  position  of 
the  forearm. 

The  forward  variety  is  more  frequent;  resulting 
directly  from  a  blow  from  behind  against  the  capitu- 
lum of  the  radius,  or  from  a  fall  upon  the  hand  during 
pronation.  The  capitulum  of  the  radius  is  situated 
in  front  above  the  eminentia  capitata,  and  causes  a 
prominence  in  the  region  of  the  supinators.  The 
forearm  is  slightly  flexed  and  pronated;  active  supi- 
nation is  impossible ;  flexion  can  be  effected  only  to 
about  a  right  angle.  The  radial  side  of  the  forearm 
is  shortened  unless  fracture  of  the  ulna  in  the  upper 
third  (which  see)  exists  as  an  important  complica- 
tion. Reduction  is  best  effected  by  vigorous  trac- 
tion, the  elbow  being  bent  and  pronated. 

In  all  these  cases  of  isolated  luxation  of  the  radius 
the  annular  ligament  is  torn,  or  the  capitulum  has 


THE    UPPER    EXTREMITY.  81 

slipped  out  of  it.  Not  rarely,  especially  in  forward 
luxation,  reduction  is  very  difficult  or  impossible 
owing  to  interposition  of  portions  of  the  capsule.  In 
the  latter  case  arthrotomy  should  be  performed  and 
the  reduction  forced  after  disengaging  the  interposed 
structures.  A  like  operation  is  indicated  in  old 
cases,  the  method  of  operation  being  a  radial  longi- 
tudinal incision  over  the  joint.  If  the  incision  were 
made  from  in  front  the  radial  nerve  would  be  liable 
to  be  divided.  Only  in  the  most  intractable  cases 
would  resection  be  indicated  instead  of  arthrotomy. 

From  a  practical  point  of  view  mention  should  here 
be  made  of  an  affection  whose  etiology  and  symptom- 
atology are  well  known,  but  whose  anatomical  details 
are  still  in  dispute.  The  affection  occurs  in  small 
children  and  results  from  violent  traction  on  the  arm 
by  the  attendant,  whether  to  avert  a  threatened  fall 
or  when  the  child  is  gliding  from  the  lap,  etc.  The 
symptoms  are :  the  child  does  not  move  the  painful 
elbow  and.  lets  it  hang  down  in  a  prouated  position ; 
there  is  no  demonstrable  deformity.  Attempts  at 
movements  of  supination  are  very  painful,  but  supi- 
nation with  traction  followed  by  flexion  causes  the 
pathological  manifestations  to  disappear.  The  child 
then  is  able  to  move  the  arm  again,  but  it  is  better 
to  keep  it  at  rest  for  a  few  days  by  means  of  a  mitella. 
This  symptom  complex  which  always  recurs  in  an 
extremely  typical  form  is  interpreted  by  some  sur- 
geons as  the  result  of  an  incomplete  forward  luxation 
of  the  radius,  by  others  as  a  consequence  of  an  incar- 
ceration of  the  intact  joint  capsule  (at  its  posterior 
surface)  between  the  capitulum  of  the  radius  and  the 
humerus. 


82  FRACTURES   AND   LUXATIONS. 

Among  incidental  injuries  lesion  of  the  radial 
nerve  has  been  particularly  observed. 

The  after-treatment  of  all  these  luxations  is  carried 
out  on  general  principles. 

6.    FOREARM. 

The  forearm  is  very  frequently  the  seat  of  fractures ; 
this  fact  finds  its  explanation  in  its  functions  during 
work  and  for  protection,  as  it  is  stretched  forward  to 
ward  off  injuries.  We  distinguish  fractures  of  the 
forearm,  i.e.,  of  both  bones,  from  isolated  fractures 
of  the  ulna  or  radius. 

A.    Fracture  of  Both  Forearm  Bones. 
{Fractura  Antibt^achii.) 

This  arises  generally  directly  from  a  fall  or  a  blow. 
In  children  infractions  with  curvatures  of  the  fore- 
arm are  not  rare. 

Sijmptoms. — Usually  the  displacement  {ad  axiu) 
at  once  calls  attention  to  the  presence  of  the  fracture; 
on  careful  examination  abnormal  mobility  and  crepi- 
tation are  discovered.  As  the  fractures  as  a  rule  oc- 
cur in  the  median  third  of  the  forearm  these  signs 
are  for  the  most  part  easily  and  positively  dem- 
onstrated. Fractures  of  the  forearm  near  the  wrist 
will  be  discussed  more  fully  in  connection  with  the 
typical  epiphyseal  fracture  of  the  radius.  When 
both  bones  are  fractured  at  the  same  level  the  dis- 
placement is  as  a  rule  greater  than  when  the  fracture 
of  the  two  bones  is  at  different  levels.  This  fact, 
too,  is  of  some  importance  for  the  prognosis.     For  a 


^  THE    UPPER    ?]XTREMITY.  83 

similar  reason  it  should  be  noted  whether  the  dis- 
placement has  caused  a  lateral  approximation  of  the 
two  bones  and  extensive  injury  of  the  interosseous 
ligament.  As  such  injury  may  be  followed  by  cica- 
tricial contraction  and  partial  ossification  of  this  liga- 
ment, and  the  bones  may  also  come  in  mutual  lateral 
contact,  whether  by  osseous  union  or  by  a  kind  of 
conical  articulation  (Plate  08,  Fig.  3),  it  is  clear  that 
the  function  of  the  forearm  with  reference  to  prona- 
tion and  supination  may  be  seriously  impaired. 
While  such  complications  are  quite  indifferent  in  the 
case  of  the  leg,  on  the  forearm  they  may  cause  per- 
manent and  grave  interference  with  the  capacity  for 
work. 

For  this  reason  the  treatment  of  fractures  of  the 
forearm  is  of  special  importance  and  should  be  car- 
ried out  with  care  and  skill.  The  aim  is  to  secure 
osseous  union  of  the  fragments  in  good  position  of 
each  bone,  with  unimpaired  mobility  of  the  two  neigh- 
boring joints  and  the  two  bones  on  each  other.  It  is 
furthermore  essential  not  to  do  harm  in  a  certain  re- 
spect by  the  dressing ;  the  latter  may  be  well  intended 
and  fit  snugly,  yet  it  may  cause  direct  injury  if  it 
presses  the  bones  together  laterally  by  circular  turns, 
that  is  to  say,  if  it  approximates  them  at  the  point  of 
fracture  so  that  they  may  completely  coalesce  when 
the  callus  formation  is  abundant.  Hence  the  splints 
should  not  be  narrow  but  broad  (perhaps  made  of 
pasteboard  and  strengthened  by  strips  of  wood),  so  as 
to  project  laterally  some  distance  beyond  the  limb. 

Another  point  which  is  of  great  importance  even 
after  the  most  careful  reposition  is  the  position  given 
to  the  forearm  in  the  dressing ;  of  course  the  elbow 


84  FRACTURES   AND   LUXATIONS. 

is  bent  at  a  right  angle,  and  the  wrist-joint,  extended, 
is  included  in  the  dressing.  But  should  the  forearm 
or  the  hand  be  in  pronation  or  in  supination?  Ac- 
cording to  the  preceding  remarks,  a  position  in  which 
the  ulna  and  radius  cross  is  to  be  absolutely  avoided ; 
in  this  respect  the  parallel  course  of  the  two  bones, 
that  is  almost  complete  supination,  is  the  best.  Fur- 
thermore, the  influence  of  muscular  traction  upon  the 
fragments  requires  attention.  On  Plate  39,  Fig.  1, 
the  influence  of  the  biceps  muscle  on  the  upper  frag- 
ment of  the  radius  is  illustrated;  this  muscle  puts  the 
bone  in  supination. 

Therefore,  were  the  dressing  applied  with  the  hand 
in  pronation  while  the  upper  fragment  of  the  radius 
remained  in  supination,  the  result  would  be  a  very 
faulty  union,  with  subsequent  loss  of  the  movement 
of  supination. 

Every  angular  position  of  the  radius  at  the  point 
of  its  fracture  is  also  liable  to  hinder  the  motions  or 
the  unfolding  of  the  interosseous  ligament,  and  thus 
limit  the  normal  excursion  with  reference  to  supina- 
tion. 

Accordingly,  after  careful  reposition  of  the  frag- 
ments, the  dressing,  including  a  splint  of  sufficient 
width,  should  be  applied  in  the  supine  position.  The 
splint  may  be  applied  to  the  dorsal  or  the  volar  side, 
best  on  both  sides,  using  a  longer  and  a  shorter 
splint.  In  these  fractures  in  particular  it  is  essential 
that  the  first  dressing  be  well  padded,  not  too  firml}^ 
applied,  and  that  the  hand  and  fingers  be  frequentl}^ 
inspected,  for  it  is  in  these  very  cases  that  gangrene 
and  ischaemic  muscular  contractures  have  been  ob- 
served as  a  result  of  tight  dressing,  especially  a  cir- 


THE    UPPEE   EXTREMITY.  85 

cular  plaster-of "Paris  bandage  applied  soon  after  the 
injury  (see  General  Remarks).  Moreover  the  change 
of  the  dressing  after  about  a  week  and  a  careful  ex- 
amination of  the  position  of  the  fragments  at  that 
time  are  very  important.  A  threatening  angular 
position  salient  on  the  extensor  side  may  be  success- 
fully treated  by  an  appropriate  splint  applied  on  the 
extensor  side,  the  elbow  being  extended.  During  the 
second  change  of  the  dressing  careful  passive  move- 
ments and  massage  are  indicated.  Irregularities  in 
course,  dela3'ed  callus  formation,  and  the  develop- 
ment of  a  false  joint  occur  occasionally  and  are  to  be 
treated  on  general  principles. 

B.    Fractures  of  the  Ulna, 
a.  Fracture  of  the  Olecranon  (Plates  SO  and  37). 

This  results  commonly  from  a  fall  upon  the  elbow, 
that  is,  from  a  direct  force,  very  rarely  from  muscu- 
lar traction  (by  the  triceps)  or  from  hyperextension, 
the  posterior  surface  of  the  humerus  crowding  against 
the  process. 

The  symptoms  are  simple,  as  the  fracture  is  nearly 
always  transverse  through  the  middle  of  the  olecra- 
non, with  a  distinct  diastasis  between  the  fragments ; 
the  upper  fragment  is  drawn  up  by  the  triceps.  As 
the  olecranon  has  a  superficial  position  it  is  readily 
felt.  The  joint  and  the  remaining  bony  prominences 
in  the  articular  region  are  intact;  only  the  effusion 
of  blood  caused  by  the  fracture  is  of  course  present 
also  in  the  joint.  Active  extension  of  the  flexed  arm 
is  impossible.  Usually  the  upper  fragment  can  be 
pushed  down  sufficiently  to  produce  crepitation  dur- 


86  FRACTURES   AXD   LUXATIONS. 

ing  lateral  movements.  Should  the  fragments  have 
remained  in  contact  (when  the  periosteal  covering 
and  the  lateral  tendinous  fibres  are  partly  intact)  the 
prognosis  is  of  course  favorable,  and  tlie  result  will  be 
firm  bony  union.  With  diastasis  of  the  fragments 
osseous  union  is  hardly  to  be  exp)ected;  on  the  con- 
trary, union  is  effected  for  the  most  part  by  connec- 
tive tissue.  This  is  to  some  extent  due  to  the  fact 
that  the  fragments  are  bare  of  periosteum  on  the  side 
directed  toward  the  joint  and  are  covered  with  thick 
cartilage,  while  on  the  outside  is  a  tense  layer  of 
fibres  (attachment  of  the  triceps  tendon) ;  as  a  result 
the  formation  of  callus  is  relatively  scant. 

Treatment. — The  first  aim  has  regard  to  the  fac- 
tors which  cause  the  diastasis;  the  arm  is  to  be 
dressed  in  complete  extension  because  thereby  the 
lower  fragment  is  most  closeh'  approximated  to  the 
upper,  w^hich  is  dra^vn  up  by  the  triceps.  Further- 
more it  is  sometimes  useful  to  remove  the  effused 
blood  from  the  joint  by  aspiration  if  the  quantity  and 
tension  increase  the  diastasis  of  the  fragments.  Be- 
sides, the  upper  fragment  should  be  brought  as  near 
to  the  forearm  as  can  be  attained  b}'  manual  fixation  ; 
this  is  effected  by  one  or  more  narrow  strips  of  adhe- 
sive plaster  which  are  looped  around  the  tip  of  the 
olecranon  above  and  pass  down  on  each  side  toward 
the  flexor  side  of  the  forearm.  The  primary  bone  su- 
ture of  the  fragments  may  be  used  under  certain  con- 
ditions, trusting  to  the  aseptic  success  of  this  opera- 
tion; however,  it  is  not  a  method  suitable  for  general 
introduction  but  is  dependent  upon  the  favorable 
auxiliaries  presented  in  a  clinic. 

That  the  injury  otherwise  is  to  be  treated  as  an  ar- 


THE   UPPER   EXTREMITY.  87 

ticular  fracture  is  obvious.  It  is  important  that 
massage  of  the  triceps  be  begun  early,  and  attention 
may  be  called  to  the  fact  that  in  most  recent  times 
the  massage  treatment  of  fractures  of  the  olecranon, 
carried  out  in  a  manner  similar  to  that  in  patellar 
fractures,  has  given  good  results. 

h.  Fractui^e  of  the  Coronoid  Process  (Plate  S7). 

This  injury  is  rare  and  is  observed  most  frequently 
in  combination  with  backward  luxation  of  the  fore- 
arm. Only  when  the  coronoid  process  is  broken  off 
at  its  base  is  the  separated  fragment  under  the  influ- 
ence of  the  brachialis  internus ;  for  this  muscle  is  not 
inserted  at  the  point  but  some  distance  below  it. 
The  fracture  in  its  pure  form  results  particularly 
from  a  force  which  moves  the  lower  end  of  the  hu- 
merus toward  the  anterior  side  of  the  ulna,  that  is, 
toward  the  coronoid  process. 

The  symptoms  are  those  of  a  severe  articular  in- 
jury. Direct  palpation  of  the  fragments  is  impossible 
owing  to  the  soft  parts  at  the  anterior  side  of  the 
■joint.  Exact  palpation  shows  that  the  bony  promi- 
nences are  intact,  only  the  olecranon  sometimes  pro- 
jects slightly  backward  (subluxation),  but  can  be 
immediately  rej)laced  by  traction  on  the  forearm. 
With  the  elbow  at  an  obtuse  angle  this  displacement 
of  the  olecranon  can  be  produced  at  once  by  back- 
ward pressure  on  the  forearm  and  again  replaced, 
when  crepitation  will  be  present. 

The  treatment  requires  complete  reposition  by  for- 
ward traction  on  the  forearm,  followed  by  fixation  in 
acute-angled  flexion ;  the  other  steps  are  those  of  ar- 
ticular fractures  in  general. 


88  FRACTURES   AND   LUXATIONS. 

c.  Fracture  of  the  Ulna  in  its  Upper  Thirds  ivith 
Lnxation  of  the  Capitulum  of  the  Radius 
{Plate  36), 

In  the  limbs  containing  two  bones,  the  forearm  and 
the  leg,  certain  findings  are  typical  and  readily  ex- 
plained. If  both  bones  are  broken  the  fracture  may 
be  associated  with  more  or  less  displacement;  the 
condition  of  the  one  bone  will  resemble  that  of  the 
other.  If,  however,  only  one  bone  is  broken  the 
other  will  act  as  a  kind  of  splint  and  may  undoubt- 
edly prevent  marked  displacement.  Therefore  if  we 
find  a  fracture  of  one  bone  with  pronounced  displace- 
ment of  the  fragments,  the  other  must  of  necessity  be 
broken  likewise  or  have  suffered  some  other  displace- 
ment, a  luxation.  In  practice  the  attentive  physician 
will  not  fail  to  observe  that  fractures  of  the  ulna, 
when  marked  displacement  is  present,  are  associated 
with  luxation  of  the  capitulum  of  the  radius;  frac- 
tures of  the  tibia,  in  like  manner,  with  luxation  of 
the  capitulum  of  the  fibula. 

Fracture  of  the  ulna  in  the  upper  third  with  con- 
siderable dislocatio  ad  axin  and  consequent  shorten- 
ing of  the  bone,  associated  with  luxation  of  the  capi- 
tulum of  the  radius  (generally  forward),  is  a  typical 
injury.  The  illustrations  on  Plate  36  are  quite  char- 
acteristic and  correspond  completely  with  what  I  have 
repeatedly  observed  in  the  living  patient.  The  evi- 
dences of  the  fracture  are  very  distinct;  there  is  never 
any  difficulty  in  the  diagnosis.  On  the  other  hand, 
the  injury  at  the  elbow  joint,  the  luxation  of  the  ra- 
dius, is  often  overlooked.  Any  one  paying  attention 
to  the  introductory  remarks  will  not  commit  this 


THE    UPPER   EXTREMITY.  89 

error.  The  displacement  of  the  fragments  is  so 
marked,  the  consequent  shortening  of  the  ulna  in  its 
longitudinal  direction  is  so  great,  that  the  radius 
must  of  necessity  be  likewise  fractured  or  luxated. 
The  surgeon  who  examines  the  elbow-joint  will  miss 
the  capitulum  of  the  radius  at  its  normal  site  and 
will  find  it  in  luxated  position  at  the  external  condyle 
or  on  the  anterior  side  of  the  joint.  The  prognosis  is 
favorable  if  the  correct  diagnosis  is  made  early;  for 
the  reposition  as  a  rule  offers  no  particular  difficulty 
when  performed  under  anaesthesia.  Vigorous  traction 
on  the  forearm  must  obtain  the  correction  of  the 
fractured  position,  while  direct  pressure  with  a  view 
to  replacement  is  exerted  on  the  head  of  the  radius 
during  flexion  of  the  forearm.  The  head  of  the  radius 
sometimes  shows  a  tendency  to  renewed  luxation  or 
forward  subluxation ;  for  this  reason  the  dressing  is 
properly  so  applied,  the  forearm  in  supine  position 
being  flexed  at  least  at  a  right  angle,  that  a  soft  pad 
in  the  bend  of  the  elbow  will  exert  gentle  pressure  on 
the  capitulum  of  the  radius. 

In  old  cases  of  this  nature  osteotomy  at  the  point 
of  fracture  and  arthrotomy  for  the  reposition  of  the 
head  of  the  radius  or  its  resection  are  required. 

d.  Fracture  of  the  Diapliysis  of  the  Ulna. 

When  a  person  falling  puts  forth  the  arm  so  as  to 
strike  on  the  forearm  with  the  elbow  bent,  or  tries 
to  ward  off  a  bloAv  with  the  arm,  the  impact  is  re- 
ceived chiefly  by  the  ulna,  which  may  be  fractured. 
These  are  direct  fractures,  and  they  may  with  justice 
be  called  parrying  fractures.  Such  injuries  result 
very  rarely  from  indirect  force.     The  diagnosis  is 


90  FRACTURES   AND   LUXATIONS. 

easily  made,  since,  owing  to  the  superficial  position 
of  the  bone,  abnormal  mobility  and  crepitation  are 
positively  demonstrated.  The  treatment  is  the  same 
as  for  fractures  of  both  forearm  bones ;  marked  dis- 
placements are  hardly  liable  to  occur  where  the  ra- 
dius is  intact. 

e.  Fracture  of  the  Styloid  Process  of  the  Ulna. 

This  occurs  very  rareh^  in  an  isolated  form,  when 
it  may  be  demonstrated  by  careful  palpation.  A 
pseudarthrosis  is  very  apt  to  develop  during  the  heal- 
ing process. 

Further  details  about  this  fracture  will  be  found  in 
the  section  on  typical  fracture  of  the  lower  epiphysis 
of  the  radius. 

C.    Fractures  of  the  Radius. 

a.   Fracture   of    the    Capitulum   of    the  Radius 
'  {Plate  31,  Fig.  Jf). 

This  of  course  presents  the  sj'mptoms  of  an  articu- 
lar lesion  and  undoubtedh'  is  not  rarely  mistaken  for 
a  simple  contusion  or  distorsion  of  the  joint.  The 
fracture  is  altogether  intra-articular;  it  may  be  com- 
plete or  incomplete  (fissure  or  infraction).  In  the 
latter  case  the  diagnosis  is  obviously  difficult  and 
doubtful.  Complete  fractures  are  recognized  by  the 
fact  that  the  capitulum  is  separately  and  abnormalh' 
movable  under  crepitation,  though  this  is  not  always 
the  case.  Particularly  during  i:>ronation  and  supina- 
tion the  associated  movement  of  the  capitulum  is 
often  undisturbed.  The  pain,  of  course,  is  limited 
to  the  region  of  the  capitulum. 


THE   UPPER   EXTREMITY.  91 

The  fracture  results  sometimes  directly,  more  fre- 
quently indirectly  from  a  fall  upon  the  hand  with  the 
elbow  extended  or  flexed,  when  a  marginal  portion 
of  the  capitulum  is  forced  off  against  the  eminentia 
capitata  (so-called  chisel  fracture). 

Treatment. — As  we  cannot  act  directly  upon  the 
separated  fragment,  union  is  often  effected  with  con- 
siderable displacement.  Evidently  the  indication  is 
to  apply  a  dressing  which  puts  the  elbow  and  wrist 
joints  at  rest,  and  perhaps  exerts  direct  pressure  upon 
the  region  of  the  capitulum  of  the  radius.  Neverthe- 
less, despite  the  employment  of  the  auxiliaries  indi- 
cated in  articular  fractures,  considerable  stiffness  of 
the  elbow-joint  not  rarely  is  left  behind  and  subse- 
quently calls  for  resection  of  the  capitulum. 

Lesion  of  the  radial  nerve  has  been  occasionally 
observed  as  an  incidental  injury. 

Fractures  of  the  neck  of  the  radius,  that  is  to  say, 
below  the  capitulum,  are  very  rare.  When  present 
the  capitulum  does  not  move  with  pronation  and  su- 
pination of  the  hand ;  a  bony  prominence  may  also 
be  felt  at  the  seat  of  the  injury.    Treatment  as  above. 

Traumatic  separation  of  the  epiphysis  at  the  upper 
end  of  the  radius  is  very  rare,  and  of  course  occurs 
only  in  children. 

h.  Fracture  of  the  Diaphysis  of  the  Radius. 

Though  fractures  of  the  shaft  of  the  ulna  are  fre- 
quent, those  of  the  shaft  of  the  radius  are  rare.  They 
may  have  a  direct  and  an  indirect  causation.  As  the 
symptoms  are  distinct,  the  diagnosis  is  readily  made. 
As  regards  the  displacement  and  the  treatment,  see 
the  section  on  fractures  of  the  forearm. 


92  FRACTURES   AND    LUXATIONS. 

c.  Fracture  of  the  Lower  Epiphysis  of  the  Radius 
(Plates  JfO,  Jfl,  Jf2). 

This  fracture  is  very  frequent  and  practically  of 
the  greatest  importance;  it  is  justly  called  typical, 
because  its  symptoms  are  extremely  characteristic 
and  despite  minor  differences  come  again  under  ob- 
servation in  every  case  of  the  kind. 

This  typical  fracture  of  the  radius  belongs  to  the 
groujD  of  supracondylar  fractures,  that  is  to  say,  the 
line  of  fracture  is  usually  located  about  one-half  to 
two  centimetres  above  the  lower  articular  surface, 
in  other  words  at  the  point  where  the  compact  bone 
of  the  diaphysis  passes  into  the  markedly  cancellous 
expansion  of  the  articular  extremity;  at  the  limit  of 
these  two  portions  fracture  is  more  liable  to  occur  for 
anatomical  and  mechanical  reasons.  Sometimes, 
however,  the  lower  fragment  does  not  include  the  en- 
tire articular  extremity ;  the  line  of  fracture  may  also 
pass  through  the  epiphysis  proper  and  lead  merely  to 
the  separation  of  a  smaller  fragment. 

The  cause  of  the  fracture  is  almost  invariablj'  a 
fall  upon  the  volar  side  of  the  hand.  The  first  result 
is  a  hyperextension  (dorsal  flexion)  which  is  checked 
by  the  strong  mass  of  ligaments  at  the  flexor  side  of 
the  wrist  joint  (ligamentum  carpi  volare) ;  greater 
force  and  continuation  of  the  movement,  however, 
do  not  cause  laceration  of  this  ligament,  but,  through 
its  influence  upon  the  lower  end  of  the  radius,  frac- 
ture at  the  point  named.  This  explanation,  there- 
fore, proves  this  to  be  a  pronounced  fracture  by  trac- 
tion, and  this  view  is  generally  accepted.  Only  in 
most  recent  times  has  this  theory  been  disputed  and 


THE    UPPER    EXTREMITY.  93 

the  claim  made  that  during  dorsal  flexion  of  the 
hand  the  upper  row  of  carpal  bones  is  forced  against 
the  dorsal  prominence  of  the  lower  end  of  the  ra- 
dius, so  that  the  fracture  would  be  due  to  inflexion 
rather  than  traction.  But  whether  the  fracture  be 
the  result  of  traction  or  of  inflexion,  the  acting  force 
always  causes  at  the  same  time  a  dorsal  displacement 
of  the  separated  lower  fragment.  That  the  lower  end 
of  the  ulna  as  a  rule  does  not  suffer  injury  is  easily 
understood  from  the  anatomical  arrangement  of  the 
parts,  since  it  has  no  direct  connection  with  the  wrist- 
joint  itself. 

When  the  fracture  results  from  a  fall  upon  the  dor- 
sum of  the  hand,  which  has  been  observed,  though 
rarely,  the  peripheral  fragment  generally  is  not  dis- 
placed dorsally  but  toward  the  palm. 

The  symptoms  of  this  fracture  must  be  determined 
by  careful  examination,  a  minute  inspection  being 
the  first  step.  It  is  best  for  the  physician  to  sit  di- 
rectly opposite  the  patient,  whose  forearms  are  bared 
and  who  places  his  two  hands  side  by  side  in  sym- 
metrical position.  If  a  fracture  is  present,  inspec- 
tion shows  the  following :  the  region  of  the  injured 
wrist-joint  is  altered,  the  styloid  process  of  the  ulna 
projecting  more  strongly  than  on  the  healthy  side 
(compare  Plate  40,  Figs.  1  and  2).  The  hand  near 
the  wrist-joint  is  displaced  radially;  but  on  tracing 
the  longitudinal  axis  in  the  middle  of  the  forearm  on 
each  side  we  find  that  this  line  on  the  healthy  side 
strikes  about  the  centre  of  the  middle  finger,  while 
on  the  injured  side  it  passes  more  toward  the  ulnar 
side.  The  region  of  the  styloid  process  appears 
widened.     All  these  symptoms  are  due  to  the  fact 


94  FRACTURES   AND   LUXATIONS. 

that  the  peripheral  fragment  (the  separated  epiphj' sis 
of  the  radius)  is  displaced  radially. 

Then  follows  inspection  from  the  side,  best  the  ra- 
dial. In  a  healthy  arm  the  lower  end  of  the  pro- 
nated  forearm  presents  at  the  radius  a  somewhat 
sinuous  line,  convex  toward  the  dorsum  and  concave 
toward  the  palm.  On  the  fractured  arm  this  line  is 
changed,  usually  in  the  opposite  way:  there  is  an 
abnormal  protrusion  on  the  flexor  side  and  a  slightly 
depressed  angle  on  the  dorsal  side.  On  tracing  the 
longitudinal  axis  of  the  forearm,  say  wdth  a  blue 
pencil  on  the  skin,  this  line  on  the  healthy  side  passes 
straight  over  the  region  of  the  wrist-joint.  It  is  in- 
terrupted, however,  on  the  injured  side,  the  line  being 
bent  in  above,  corresponding  to  the  epiphysis  of  the 
radius;  in  tliis  way,  w^ien  the  hand  is  extended 
straight,  a  baj^onet-like  direction  results  which  is 
characteristic  of  this  fracture.  This  kind  of  dis- 
placement finds  its  simplest  explanation  by  the  con- 
tinuation of  the  force  acting  during  the  injury.  As 
soon  as  the  fracture  has  resulted,  the  weight  of  the 
falling  body  must  continue  to  act  until  the  diaphy- 
seal end  of  the  radius  reaches  the  ground.  In  this 
way  the  epiphyseal  fragment  suffers  an  upward  dis- 
placement; it  comes,  as  it  were,  in  a  somewha,t  su- 
pine position,  while  the  shaft  of  the  radius  undergoes 
pronation.  In  this  occurrence,  of  course,  the  connec- 
tion of  the  lower  end  of  the  radius  with  the  ulna  is 
of  importance :  the  displacement  is  effected  in  such  a 
way  that  the  lower  end  of  the  ulna  forms  approxi- 
mately the  centre  for  the  movement  of  the  radius  in 
consequence  of  the  ligamentous  connection  between 
the  ends  of  the  two  bones.     It  is  possible  that  muscu- 


THE    UPPER   EXTREMITY.  95 

lar  action  may  play  a  part  in  the  production  of  this 
typical  displacement,  but  the  main  point  lies  in  the 
force  at  work,  as  has  just  been  briefly  explained. 

The  other  symptoms  of  a  fracture  are  not  always 
pronounced.  Abnormal  mobility  is  generally  not 
easily  demonstrable;  in  order  to  prove  its  presence 
the  epiphyseal  fragment  must  be  very  firmly  fixed 
and  the  injured  arm  be  given  some  support  by  rest- 
ing it  against  the  examiner's  body.  But  it  is  not  nec- 
essary to  force  the  demonstration  of  this  symptom. 
A  similar  remark  applies  to  crepitation,  but  a  char- 
acteristic snapping  or  rubbing  is  more  frequently 
felt.  Of  greater  importance  is  the  demonstration  of 
the  painful  spot ;  on  palpating  the  radial  side  of  the 
articular  region  the  line  of  the  joint  itself  and  even 
the  styloid  process  of  the  radius  will  be  painless, 
while  about  one  or  two  centimetres  above  the  typical, 
pain  is  experienced.  During  this  palpation  the  result 
of  the  inspection  is  confirmed.  We  feel  particularly 
the  abnormal  bony  prominence  at  the  seat  of  the  frac- 
ture on  the  volar  side  and  the  depressed  angle  on  the 
dorsal  side. 

The  prognosis  of  the  fracture  depends  in  the  main 
upon  the  treatment. 

Treatment. — The  first  requirement  is  to  effect 
exact  reposition,  which  is  done  by  forced  flexion  and 
traction,  best  under  anaesthesia.  In  many  cases, 
after  careful  reposition,  there  is  no  tendency  for  the 
displacement  to  recur.  Still  it  is  desirable  to  follow 
certain  rules  in  applying  the  dressings.  The  latter 
should  include  the  entire  forearm,  the  wrist-joint, 
and  the  metacarpals.  The  elbow-joint  need  not  be, 
and  the  fingers  must  not  be,  fixed ;  for  in  many  pa- 


96  FRACTURES   AND    LUXATIONS. 

tients  the  fixation  of  the  fingers  is  very  apt  to  lead  to 
excessive  stiffness,  which  subsequently  requires  pain- 
ful treatment  (massage  and  mobilization)  and  some- 
times cannot  be  completely  relieved. 

In  order  to  retain  the  lower  fragment  in  place  the 
hand  should  be  in  a  certain  position,  this  being  the 
only  way  in  which  the  short  fragment  can  be  acted 
upon.  The  hand  must  be  in  volar  and  at  the  same 
time  in  ulnar  flexion;  thus  the  recurrence  of  the  dis- 
placement will  be  prevented.  Reposition  should  not 
be  forgotten,  nor  during  the  dressing  that  the  hand 
(with  the  fragment)  as  a  whole  is  disj^laced  toward 
the  ulna,  otherwise  a  disfiguring  prominence  of  the 
styloid  process  of  the  ulna  will  remain  behind. 

It  is  immaterial  whether  this  object  is  attained  in 
one  or  the  other  way  when  the  dressing  is  applied. 
A  Beely's  plaster-of-Paris  splint  (Plate  42,  Fig.  2) 
is  quite  suitable,  or  else  the  application  of  a  small 
bent  splint  which  fixes  the  hand  in  the  desired  posi- 
tion. If  a  splint  must  be  improvised  from  a  piece  of 
nasteboard  or  wooden  board,  only  ulnar  flexion  can 
be  secured  by  the  form  of  the  splint  (pistol-shaped 
splint) ;  in  that  case  it  will  be  a  good  plan  to  place 
a  soft  roller  under  the  epiphyseal  end  of  the  radius 
so  as  to  keep  it  somewhat  elevated ;  vrhile  the  diaphy- 
seal end,  being  not  so  supported,  sinks  a  little.  Roser's 
splint  dressing  (Plate  42,  Fig.  3)  is  applied  in  full 
supination,  the  patient  as  it  were  looking  into  his 
own  palm.  This  dressing  is  somewhat  bulky  but 
gives  good  results.  Of  course  it  is  essential  that  the 
injury  be  treated  as  an  articular  fracture,  with  fre- 
quent change  of  dressings,  early  massage,  etc. 
Quite  recently  attention  has  again  been  called  to  the 


THE   UPPER    EXTREMITY.  97 

fact  that  the  fracture,  if  the  fragments  have  been 
properly  replaced,  will  unite  without  any  dressing, 
being  simply  placed  in  a  mitella,  with  the  best  results 
as  regards  mobility  of  the  wrist-joint.  But  for  vari- 
ous reasons  this  is  not  to  be  recommended  for  general 
acceptance.  There  is  no  question  that  it  is  always 
better  to  have  the  fracture  unite  with  some  displace- 
ment but  with  good  mobility,  than  without  displace- 
ment and  with  great  impairment  of  the  function  of 
the  wrist-joint. 

When  the  fracture  is  associated  with  a  fracture  of 
the  styloid  process  of  the  ulna,  that  is  to  say,  in  the 
case  of  a  fracture  of  both  forearm  bones  at  their 
lower  ends,  the  wrist-joint  is  particularly  liable  to  be 
involved.  In  general  this  fracture  is  to  be  treated  on 
the  same  principles ;  in  some  cases  it  has  been  found 
necessary  later  on  to  resect  the  styloid  process  of  the 
ulna  in  order  to  improve  the  mobility. 

D.     Luxation    in    the    Lower     Radio-Ulnar 
Articulation. 

Despite  the  weak  ligamentous  apparatus,  and  de- 
spite the  frequency  with  which  this  region  is  acted 
upon  by  extraneous  forces,  this  luxation  is  very 
rare.  The  lower  articular  end  of  the  ulna  may  be 
dislocated  dorsally  (directly  by  a  fall  or  through  ex- 
cessive pronation),  or  toward  the  palm  (directly  or 
through  excessive  supination).  The  symptoms  are 
determined  by  careful  palpation.  A  subluxation  at 
this  joint  occurs  in  washerwomen  from  wringing 
clothes.  The  treatment  is  carried  out  on  general 
principles. 


98  FRACTURES   AND   LUXATIONS. 


7.    WRIST-JOINT. 

Luxation  of  the  hand  at  the  radio-carpal  joint  is  ex- 
tremely rare.  Although  this  diagnosis  was  formerly 
often  made,  it  is  now  known  that  the  large  majority 
of  cases  were  typical  fractures  of  the  epiphysis  of  the 
radius.  The  cases  of  true  luxation  which  have  been 
positively  demonstrated  may  easily  be  counted  (about 
thirt}'),  and  moreover  are  complicated  in  part  with 
fracture  of  the  styloid  process  of  the  radius. 

The  luxation  may  be  dorsal  or  volar;  the  carpus 
then  is  situated  on  the  dorsal  or  volar  side  of  the  ar- 
ticular ends  of  the  forearm  bones.  The  injury  results 
from  a  fall  upon  the  outstretched  hand  in  pronounced 
dorsal  (dorsal  form)  or  volar  (volar  luxation)  flexion. 
The  diagnosis  is  made  by  careful  palpation ;  reduc- 
tion is  effected  by  traction  and  direct  pressure. 

8.    HAND    AND    FINGERS. 

A.    Fractures. 

Fractures  of  the  carpal  bones  are  rare  and  have  been 
observed  usually  in  combination  with  severe  lacera- 
tions or  contusions  of  the  overlying  soft  parts.  The 
grade  of  the  lesion  depends  upon  these  complicating 
injuries. 

Fractures  of  the  metacarpal  bones  are  not  so  rare 
and  result  directly  from  impacts  or  blows  upon  the 
dorsum  of  the  hand.  Usually  abnormal  mobility  and 
crepitation  can  be  demonstrated,  together  with  vio- 
lent pain  at  the  point  of  fracture.  Displacement  is 
absent  as  a  rule,  for  the  bones  are,  as  it  were,  splinted 


THE    UPPER    EXTREMITY.  99 

by  one  another.  The  treatment  therefore  is  simple. 
Unless  direct  pressure  be  required  occasionally  for  the 
retention  of  a  fragment,  a  simple  circular  bandage  and 
mitella  sufifice ;  early  massage  and  exercise  of  the  fin- 
gers are  useful. 

Fractures  of  the  phalanges,  usually  from  direct 
force,  may  also  result  indirectly  from  a  force  acting 
in  the  longitudinal  direction  of  the  phalanges  (with 
consequent  longitudinal  fracture) ;  it  is  said  that  they 
may  occur  on  the  ungual  phalanx  even  from  traction 
of  the  extensor  tendon  during  forced  flexion  (fracture 
by  traction).  The  diagnosis  and  treatment  (small 
padded  splint)  of  these  injuries  are  very  simple,  ow- 
ing to  the  superficial  location  of  the  parts. 

B.    Luxations. 

Luxation  at  the  intercarpal  joint,  the  two  rows  of 
carpal  bones  being  displaced  on  ^each  other,  is  ex- 
tremely rare.  The  luxation  of  single  carpal  bones  is 
not  quite  so  rare.  Of  course  the  dislocated  bone  forms 
a  prominence  by  whose  shape  and  location  the  diag- 
nosis is  made. 

Luxation  at  the  carpo-metacarpal  joints  likewise 
has  been  rarely  observed,  the  most  frequent  being  the 
one  at  the  thumb,  where  a  dorsal,  more  rarely  a  volar, 
and  a  radial  dislocation  of  the  first  metacarpal  occur. 
The  abnormal  prominence  and  the  direction  of  the 
shaft  of  the  metacarpal  determine  the  diagnosis;  re- 
duction is  effected  by  traction  and  direct  pressure. 

Luxation  at  the  metacarpo-phalangeal  joints 
(Plates  43  and  44)  is  rare  on  the  four  fingers,  but  is 
more  frequent  on  the  thumb,  and  very  important  prac- 


100  FRACTURES   AND   LUXATION'S. 

tically.  Luxation  of  the  thumb  as  a  typical  injury  is 
always  dorsal,  that  is  to  say,  the  base  of  the  first 
phalanx  is  dislocated  upon  the  dorsal  side  over  the 
head  of  the  first  metacarpal.  The  luxation  of  the 
thumb  may  be  incomplete,  when  the  two  articular 
surfaces  are  still  in  contact,  or  complete,  when  they 
are  fully  separated.  This  luxation  can  be  easily  pro- 
duced artificially  in  the  cadaver  b}'  hyperextension 
(maximal  dorsal  flexion)  and  a  vigorous  backward 
push  toward  the  wrist-joint  of  the  first  phalanx  thus 
dislocated.  When  the  thumb  by  some  slight  flexion 
is  again  brought  into  an  almost  straight  position,  all 
the  characteristic  symptoms  of  the  typical  luxation  of 
the  thumb  are  present.  I  have  even  observed  inter- 
position with  impossible  reduction,  which  will  be  dis- 
cussed hereafter. 

The  essential  point  in  artificial  luxation,  as  in  that 
observed  during  life,  is  the  fixation  of  the  dislocated 
thumb.  This  results  from  the  traction  of  the  soft 
parts  appertaining  to  the  joint  and  surrounding  it. 
The  lateral  ligaments  frequently  are  not  torn,  and  a 
number  of  powerful  muscles  and  tendons  effect  the 
fixation  by  closely  hugging  the  head  of  the  metacar- 
pal at  the  same  time.  Thus  is  caused  a  kind  of  ob- 
struction to  the  reduction  when  the  faulty  eff'ort  is 
made  to  do  so  by  simple  traction;  the  stronger  the 
traction  the  more  closely  and  tightly  the  tendons  and 
muscles  hug  the  neck  of  the  caj^itulum,  and  thereby 
increase  the  difficulty  (the  so-called  buttonhole  mech- 
anism, compare  Plates  43  and  44,  Fig.  1). 

Symptoms. — The  bayonet-like  direction  of  the 
thumb  in  connection  with  the  first  metacarpal,  to- 
gether with  the  marked  prominence  of  the  head  of 


THE    UPPER   EXTREMITY.  101 

the  latter  bone  on  the  volar  side,  the  presence  of  the 
abnormal  direction  of  the  first  phalanx,  as, well  as 
the  peculiar  firm  fixation  in  this  position — all  these 
lead  to  the  correct  diagnosis. 

The  reduction,  as  in  all  hinge  joints,  should  be 
effected  without  force.  The  thumb  is  first  hyperex- 
tended  and  then  pushed  forward  by  direct  pressure 
against  the  base  of  the  first  phalanx.  As  soon  as  the 
greater  part  of  the  articular  surfaces  have  come  into 
normal  contact  flexion  will  succeed  and  the  reduction 
is  complete. 

Stress  is  to  be  laid  upon  the  correct  performance  of 
this  manipulation,  and  yet  the  reduction  may  fail  in 
spite  of  it. 

A  frequent  cause  of  obstruction  is  found  in  the  in- 
terposition of  the  capsule,  sometimes  also  of  the  sesa- 
moid bones.  In  other  cases  I  have  found  a  peculiar 
relation  of  the  tendon  of  the  flexor  pollicis  longus  to 
be  a  cause  of  obstruction,  and  this  not  only  during  life 
but  also  when  the  luxation  was  artificially  produced 
in  the  cadaver.  The  tendon  surrounds  the  neck  of 
the  first  metacarpal;  when,  as  sometimes  happens, 
the  articular  surface  of  the  capitulum  terminates  on 
the  ulnar  side  in  a  thick  expansion,  the  tendon  may 
be  almost  incarcerated  behind  it,  and  reduction  be 
rendered  impossible.  This  condition  may  sometimes 
be  recognized  by  a  slight  inclination  and  twisting  of 
the  thumb  toward  the  ulnar  side;  occasionally  but 
not  always  the  incarceration  of  the  tendon  may  be 
overcome  by  a  greater  inclination  toward  this  side. 

Exceptionally  it  may  happen  during  reduction,  es- 
pecially if  carried  out  incorrectly  by  traction  upon  the 
thumb,  that  the  capsule  and  the  external  sesamoid 


102  FRACTUKES  AND   LUXATIOXS. 

bone  are  turned  over  and  interposed  in  an  inverse 
direction  between  the  articular  ends  (complex  luxa- 
tion) . 

Reduction  having  failed,  arthrotoniy  should  be  im- 
mediately performed.  In  all  cases  of  this  nature  I 
have  succeeded,  by  a  preparatory  incision  over  the 
capitulum  projecting  on  the  volar  side,  in  finding  the 
obstruction  to  the  reduction,  in  effecting  the  latter, 
and  in  securing  a  movable  joint.  In  very  old  cases 
resection  of  the  capitulum  might  be  necessary. 

After  these  explanations  and  a  careful  inspection  of 
Plates  -43  and  44  nothing  further  need  be  said  regard- 
ing the  sj'mptoms  and  treatment  of  the  much  rarer 
volar  luxation  of  the  thumb  and  the  somewhat  more 
frequent  luxation  at  the  interphalangeal  joints.  The 
above-described  relations  of  the  dorsal  luxations  of 
the  thumb  apply  more  or  less  closely  also  to  these 
forms  of  dislocation. 


V. 

FKACTUIIES  AND  LUXATIONS 


OF   THE 


LOWER    EXTREMITY. 


Explanation   of  Plate  45. 
Fractures  of  the  Pelvis.     Bektini's  Ligament. 

Fig.  1. — The  lines  of  fracture  in  the  anterior 
circumference  of  the  pelvic  ring,  on  both  sides  of 
the  symphysis  pubis,  correspond  to  those  which  may 
be  produced  artificially  by  compressing  the  pelvis  in 
a  direction  from  before  backward.  The  fracture 
shown  resulted  from  being  run  over;  the  patient,  an 
adult,  lying  on  the  back.  Besides  the  separation  of 
the  anterior  middle  portion  there  is  a  duistasis  of 
one  sacro-iliac  symphysis.  In  other  cases  there  is 
in  addition  a  fracture  of  the  sacrum  or  of  the  venter 
of  the  ilium.  Sometimes  there  occurs  in  one  half  of 
the  pelvis  a  fracture  in  front  through  the  bones  sur- 
rounding the  obturator  foramen,  behind  through  the 
venter  of  the  ilium,  i.e.,  Malyaigne' s  double  vertical 
fracture. 

Fig.  2. — Pelvic  fr act U7'e  through  the  acetabnlnm 
in  a  boy  aged  14  (W.  Kohn,  1889;  see  description  of 
Fig.  1,  Plate  1).  He  was  injured  by  the  cam- wheels 
of  a  threshing  machine.  Among  the  incidental  in- 
juries was  a  large  flap  wound  of  the  left  inguinal 
region,  at  the  bottom  of  which  the  femoral  vessels  laj' 
as  if  dissected  free,  and  which  led  into  a  large  wound 
cavity  between  the  adductors,  where  the  bones  sur- 
rounding the  obturator  foramen  could  be  felt  to  be 
fractured.  The  left  thigh  was  slightly  adducted  and 
appeared  shortened.  The  penis  was  complete^  flayed. 
The  urethra  was  intact;  the  catheter  evacuated  nor- 
mal urine.  The  wounds  were  dressed  without  anaes- 
thesia and  the  bleeding  vessels  ligated ;  infusion  of 
oOO  cc.  salt-and-sugar  solution.  Still,  collapse  and 
death  ensued  in  a  few  hours.  The  fracture  involved 
the  left  OS  pubis  and  the  ischium,  and  had  caused  in 
the  acetabulum  a  wide  diastasis  of  the  Y-shaped  sym- 
physis. 

Fig.  '5. — Illustration  of  the  ileo-femoral  or  Ber- 
tini^s  ligament,  whose  importance  for  luxations  of 
the  hip- joint  was  demonstrated  by  Bigelow.  The 
femur  is  in  the  position  of  an  iliac  luxation, 

54 


Fig.1 


Fig  3 


Lilh  Anst  v.F.Reichhold.Munchen 


Fi^l 


Fy2 


Lith. Anst  v.F.Reichhold.Miinchen . 


Explanation  of  Plate   46. 

Luxation  of  the  Thigh. 

The  normal  rotary  inovements  at  the  hip- joint  are 
inward  and  outward.  On  looking  at  a  person  from 
in  front  and  bearing  in  mind  the  normal  form  of  the 
upper  end  of  the  femur,  it  is  easy  to  conceive  how 
these  rotary  movements  are  effected  around  the  head 
of  the  femur  as  a.  centre  and  with  the  length  of  the 
neck  of  the  femur  as  the  radius.  When  outward  rota- 
tion is  forced  the  joint  capsule  at  its  anterior  cir- 
cumference is  rendered  very  tense,  and  wdien  this  out- 
ward rotation  is  continued  the  capsule  tears  in  front 
and  the  head  of  the  femur  may  undergo  forward  lux- 
ation. When  inward  rotation  is  forced  the  joint  cap- 
sule may  tear  in  its  posterior  circumference,  and  a 
posterior  or  backward  luxation  of  the  femur  may 
result.  Both  forms  of  luxation  occur  more  readily 
when  the  thigh  is  bent  at  the  same  time  to  about  a 
right  angle  in  the  hip-joint,  but  even  then  powerful 
force  is  required,  and  not  rarely  an  injury  of  the  liga- 
mentous apparatus  or  of  the  bones  occurs  previousl}^ 
at  the  knee-joint,  which  renders  an  increase  of  the 
movement  leading  to  luxation  impossible. 

Fig.  1  shows  a  backivard  luxation  of  the  femur j 
we  see  the  characteristic  inward  rotation  of  the  thigh 
w^th  moderate  adduction.  The  illustration  w^as  drawn 
from  a  photograph  of  an  adult  whose  iliac  luxation 
was  reduced  w^ithout  difficulty  under  anaesthesia. 

Fig.  2. — Forivard  luxation  of  the  femur j  the 
head  is  in  the  region  of  the  obturator  foramen.  The 
thigh  is  rotated  outward  and  flexed  farther.  This 
obturator  luxation  was  produced  artificially  and  the 
drawing  made  from  a  photograph. 


00 


Explanation  of  Plate  47. 
Luxation  of  the  Thigh. 

Posterior  luxation  of  the  femur.  This  luxation 
"vvas  artificially  produced  in  the  cadaver,  and  then  used 
for  the  preparation  here  illustrated. 

On  the  plate  the  normal  head  of  the  femur  can  he 
recognized  at  once;  it  is  dislocated  backward  and 
could  be  felt  there  through  the  overljing  soft  parts. 
A  portion  of  the  neck  of  the  femur  is  also  visible. 
The  glutceus  maximus  is  divided  in  the  direction  of 
its  fibres  and  the  two  portions  are  drawn  wide  apart. 
Beneath  the  upper  portion  of  the  gluteeus  maximus, 
which  is  fixed  by  a  hook,  a  strip  of  the  gluteeus  mini- 
mus is  visible,  and  beneath  the  latter  the  pj-riformis; 
we  see  it  emerging  from  the  lesser  pelvis  (whose  mar- 
gin appears  above)  and  passing  to  the  great  trochanter 
immediately  over  the  luxated  head.  In  a  median 
direction  from  the  head  of  the  femur  the  sciatic  nerve, 
distinguished  by  a  yellow  color,  is  dissected  free;  it 
is  also  easily  recognizable  by  its  course.  Between  this 
nerve  and  the  gluteeus  maximus  we  see  the  tuberosity 
of  the  ischium,  and  the  tendon  of  the  biceps  femoris 
springing^  from  it.  Under  the  head  of  the  femur 
some  other  muscles  are  visible  which  surround  the 
femur  like  a  cravat.  These  are,  first,  above  the  ob- 
turator externus  and  beneath  it  the  quadratus  femoris, 
whose  fibres  are  parth'  lacerated.  Between  the  mid- 
dle of  the  head  of  the  femur  and  the  sciatic  nerve  a 
reddish  strip  of  muscle  is  to  be  seen ;  this  is  the  ob- 
turator internus,  which  is  situated  between  the  head 
and  the  margin  of  the  acetabulum.  Hence,  after 
Avhat  has  ijeen  stated,  this  is  the  so-called  sciatic  lux- 
ation. The  illustration  is  very  characteristic  and 
gives  a  good  idea  of  the  large  mass  of  muscles  whose 
tension  is  to  be  overcome  in  the  reduction  of  luxa- 
tions at  the  hip-joint.  For  this  reason  profound  anaes- 
thesia is  al\va3'S  indicated,  in  order  that  the  reduction 
may  be  accomplished  when  the  muscles  are  relaxed. 

56 


MM  gliU  rna^rt:  ctnt^d^ 
M glut  mmim!     ., ., 


Mpyrtformis 


M.  obtural.  inJ> 


Tub.  ischU 


M  obtural 
exterrv 


M  quadrat 
fcnior 


^/^ischz4zd^ 


Lith.Anst  v  F.Reichhold.MiJnchen 


Mr^c^  crur. 


M  sartvnits 


,  M.pecUneus 
\    laceratiLS 


MMaddivct. 


Ll^h  Anst  v  F  Rcichhold.Munchen 


Explanation  of  Plate  48. 
Luxation  of  the  Thigh. 

Forward  luxation  of  the  femur.  This  luxation 
likewise  was  artificially  produced  in  the  cadaver  and 
then  dissected  and  drawn. 

The  position  of  the  entire  limb  is  characteristic. 
Here,  too,  we  recognize  at  once  the  head  of  the  femur 
covered  by  the  torn  fibres  of  the  pectineus  muscle. 
This  laceration  of  muscles  occurs  also  in  the  living 
subject,  and  for  this  reason  the  effusion  of  blood  in 
luxation  of  the  hip  is  often  very  great;  but  in  this  in- 
stance it  may  also  be  in  part  a  x30st-mortem  phenom- 
enon, that  is  to  say,  it  may  depend  on  the  greater 
friability  and  brittleness  of  the  muscles  in  a  cadaver 
which  is  not  quite  fresh.  Inward  from  the  head  of 
the  femur  are  the  adductors;  outward,  and  upward 
are  the  femoral  vein  and  artery,  then  the  crural  nerve 
(yellow)  imbedded  in  the  muscle,  then  the  rectus 
f  em  oris  and  the  sartorius.  Between  the  femoral  vein 
and  the  head,  above  the  latter,  is  the  region  of  the 
crural  ring. 

It  may  be  easily  recognized  that  the  head  of  the 
femur  is  situated  in  the  region  of  the  obturator  fora- 
men; it  is  an  obturator  luxation.  Reduction  was 
readily  effected  by  inward  rotation  of  the  slightly 
flexed  thigh. 

A  second  variety  of  forward  dislocation,  as  is  well 
known,  is  the  puhic  luxation.,  in  which  the  head  is 
situated  on  the  crest  of  the  os  pubis ;  the  thigh  is  like- 
w^ise  rotated  outward  and  flexed,  but  not  nearl}'  so 
much  as  in  obturator  luxation. 


57 


Explanation   of  Plate   49. 

Extracapsular    Fractures    of    the   Neck  of 

THE  Femur. 

It  is  a  well-known  fact  that  fixictnres  of  the  neck 
of  the  feniiLv  are  diYided  into  extracapsular  and  intra- 
capsular, according  to  ^vhether  the  line  of  fracture 
separates  the  neck  nearer  to  the  great  trochanter  (ex- 
tracapsular) or  closer  to  the  head  (intracapsular). 
These  terms  are  not  quite  exact  as  expressing  the  re- 
lation to  the  joint  capsule,  but  they  may  be  retained 
in  the  above  anatomical  sense. 

All  the  illustrations  on  Plate  40  represent  extra- 
capsular  fractni^es  of  the  neck  of  the  femur. 

Fig.  1  a  and  h. — Fracture  of  the  neck  of  the  femur 
of  an  old  woman  who  was  injured  b}^  a  fall  upon  the 
trochanter.  The  fracture  is  a  pronounced  extracap- 
sular one,  it  passes  even  within  the  trochanter  and 
forms  the  condition  of  the  fragments  known  as  im- 
paction (gom pilosis).  In  Fig.  1  6  we  see  the  external 
form,  in  Fig.  1  a  the  section  of  the  specimen.  The 
impaction  manifests  itself  in  the  shortening  of  the 
neck  of  the  femur,  which,  moreover,  is  almost  at  a 
right  angle  to  the  shaft  of  the  femur ;  on  the  great 
trochanter  we  also  recognize  the  infracted  form.  The 
red  line  drawn  on  Fig.  1  a  shows  the  form  of  the 
upper  end  of  the  femur  of  the  healthy  side,  divided 
in  like  manner.  This  marks  ver}-  clearl}^  the  shorten- 
ing of  the  fractured  bone.      (Author's  collection.) 

Fig.  2  a  and  h. —  United  extracapsidar  fracture 
of  the  neck  of  the  femur  in  a  woman  (Glowe)  aged 
82,  who  was  injured  in  November,  1888.  After  her 
death  (in  the  beginning  of  March,  1893),  the  speci- 
men shown  was  found  at  the  autopsy.  It  was  im- 
possible to  make  a  comparison  with  the  opposite  side 
because  it  also  contained  a  fracture  of  the  neck  of 
the  femur,  which  is  illustrated  in  Fig.  2,  Plate  50. 
(Author's  collection.) 

58 


/ijr  2' 


Eii).2* 


Lith.Anst.v.F.Rcichhold.MiJnchen. 


Fi^.1 


Fi(^  2' 


Fcg.2' 


Ah  Anst  v.r.Reichhoid,Mj,.tI»en 


Explanation  of  Plate    50. 

Intracapsular    Fractures    of    the    Neck    of 

THE  Femur. 

We  see  very  distinctly  that  the  neck  of  the  femur 
has  retained  its  connection  with  the  trochanter  and 
the  shaft,  and  that  really  only  the  head  of  the  femur 
is  broken  off. 

The  specimen  illustrated  in  Fig.  1  a  and  h  is  ex- 
tremely characteristic  of  those  cases  in  which  the  head 
of  the  femur  is  situated  in  the  acetabulum  and  its 
fractured  surface  corresponds  with  the  level  of  the 
margin  of  the  socket.  Between  this  fractured  surface 
of  the  head  and  the  fragment  of  the  shaft  a  kind  of 
nearthrosis  has  developed  in  consequence  of  the  dis- 
placement there  occurring.  The  neck  of  the  femur 
has  been  worn  away  in  the  course  of  time  so  that  it 
has  actually  disappeared.  Of  interest  is  a  condition 
of  pronounced  arthritis  deformans  which  has  led  to 
deposits  of  bone  at  the  margin  of  the  acetabulum  and 
the  upper  end  of  the  shaft  of  the  femur;  the  latter  is 
thickened  almost  to  a  club  shape  by  massive  bone 
formation,  and  is  flattened  at  its  articulation  with  the 
pelvis,  where  it  shows  in  part  a  dense  spongy  mass  of 
bone,  in  part  also  distinct  abraded  surfaces  such  as 
are  frequent  in  arthritis  deformans ;  at  the  fractured 
surface  of  the  head  similar  abrasions  are  barely  indi- 
cated.    (Author's  collection.) 

Fig.  2  a  and  b. — This  is  the  specimen  from  the  op- 
posite side  of  the  fracture  of  the  neck  of  the  femur 
shown  in  Fig.  2,  Plate  39,  from  the  same  woman, 
aged  82,  namely,  an  intraccvpsular  fracture  of  the 
neck  of  the  femur  ivith  impaction.  The  shorten- 
ing of  the  neck  of  the  femur  caused  thereby  is  espe- 
cially marked  in  Fig.  2  h.  Here,  therefore,  the  frac- 
tured end  of  the  neck  of  the  femur  is  wedged  in  the 
cancellous  tissue  of  the  head,  in  the  same  way  as  it 
may  be  impacted  in  the  mass  of  the  trochanter  in 
extracapsular  fractures. 

59 


Explanation  of  Plate   51. 

Typical    Displacement    in    Fracture    of    the 
Thigh  at  the  Middle. 

Fig.  1. — Picture  of  Ernst  Gottschalk,  a  boy  aged  8, 
admitted  October  30th,  1889,  with  a  badly  nutted 
fracture  of  the  femur.  His  thigh  had  been  frac- 
tured on  March  23d  of  the  same  year,  and  had  been 
treated  with  plaster-of- Paris  dressings.  The  deform- 
ity on  admission  is  apparent  in  the  ilhistration  drawn 
from  a  photograph;  the  right  thigh  is  considerably 
shorter  than  the  left,  hence  the  right  half  of  the  pel- 
vis is  lowered;  besides  the  thigh  shows  an  angle 
salient  forward  and  outtcard.  The  gait  of  course 
was  limping  and  laborious.  Under  anaesthesia  osteo- 
clasis at  the  point  of  fracture  succeeded  without  diffi- 
culty. By  the  aid  of  a  correct  adhesive-plaster  trac- 
tion dressing  and  a  pull  by  heavy  weights,  the  thigh 
being  in  moderate  flexion  and  abduction,  union  was 
secured  in  a  straight  line  with  barely  any  shortening. 

The  deformity  alluded  to  is  typical  in  fractures  of 
the  thigh  at  or  slightly  above  its  middle.  It  is  due 
to  the  ileo-psoas  muscle  acting  unilateralh'  upon  the 
upper  fragment  and  to  the  muscles  inserted  at  the 
great  trochanter  (glutseus  maximus,  etc.). 

Fig.  2  is  to  call  to  mind  these  muscles  and  their 
action  upon  the  upper  fragment  of  the  femur.  The 
illustration  is  carefully  drawn  from  nature  (prepa- 
ration). Of  the  trochanteric  muscles  onh^  the  glutreus 
medius  c(nild  be  represented,  because  it  alone  reaches 
far  enough  forward  on  the  crest  of  the  pelvis  to  be 
seen  in  this  view. 


60 


Mileo  -psoas 
M.ghit.  med^.    ; 


Fiy.l 


Lith.Anst  v.F  Reichhold.Miinchen. 


Fragrrurnt.  supertus 
Femur 
Fragment  infe^ias 


LiJh.Anst  v  r  Reichhold.Munchen 


Explanation  of  Plate   52. 

Typical    Displacement    of  the   Fragments   in 
Supracondylar  Fracture  of  the  Femur. 

The  illustration  was  drawn  from  an  artificial  prep- 
aration in  which  the  displacement  of  the  fragments 
was  made  analogous  to  the  typical  displacement  in  the 
living  patient.  In  the  illustration  we  notice  at  once 
the  fractured  surface  of  the  lower  fragment  which  is 
placed  in  flexion  by  the  traction  of  the  calf  muscles 
and  therefore  projects  backward.  Above  it  may  be 
seen  the  shaft  of  the  femur,  the  upper  fragment. 
Very  interesting  is  the  relation  of  the  vessels  (ouly 
the  artery  is  shown  here),  which  as  it  were  ride  upon 
the  protruding  edge  of  the  lower  fragment — a  con- 
dition which  has  been  repeatedly  noted  in  the  litera- 
ture and  which  sometimes  has  led  to  gangrene  of  the 
extremity. 

A  similar  displacement  has  also  been  observed  in 
traumatic  separation  of  the  epiphysis  at  this  point, 
in  young  persons. 

In  order  to  prevent  a  displacement  of  the  fragments 
in  this  way  we  must,  after  careful  reposition,  resort 
to  a  traction  dressing  with  heavy  weights  and  to 
direct  pressure  against  the  lower  fragment  close  above 
the  popliteal  space  by  pulleys  or  Avound  rollers.  Oc- 
casionally, however,  it  may  be  necessary  to  bend  the 
knee  at  a  right  angle  and  apply  the  dressing  so  as  to 
secure  forward  traction,  in,  a  manner  resembling  the 
older  treatment  of  fracture  of  the  femur  by  the  so- 
called  equilibrium  method  or  the  double  inclined 
plane,  etc. 


61 


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Lilh  Anst  V  F  ReJchhold.Munchen 


Explanation   of  Plate    64. 

Vertical    Extension     in    Fractures    of    the 
Femur  in  Children. 

While  the  adhesive-plaster  traction  dressing  in 
the  treatment  of  fractures  of  the  fenmr  is  generall}' 
well  established,  the  same  cannot  be  said  of  its  minor 
modifications.  Yet  it  is  impossible  to  heal  every  frac- 
ture of  the  femur  with  the  simple  adhesive-plaster 
traction  dressing  in  the  manner  desired,  even  when 
rather  heavy  weights  are  employed.  In  some  cases 
all  that  is  necessary  to  avoid  serious  displacement  is 
to  place  the  entire  limb  in  moderate  flexion  and  ab- 
duction so  as  to  bring  the  lower  fragment  into  equal 
position  with  the  upper  which  is  influenced  by  mus- 
cular traction.  In  other  cases  lateral  traction  is  re- 
quired in  addition,  as  a  rule  traction  inward  and  back- 
ward in  order  to  prevent  an  angle  salient  forward  and 
outward.  This  is  best  effected  by  a  loop  of  adhesive 
plaster  (sometimes  two  are  needed,  acting  in  different 
directions),  which,  being  fastened  to  the  prominent 
portion,  produces  the  desired  effect  b}'  means  of  a 
cord  and  weight  attached  to  it. 

In  children  under  five  years,  sometimes  also  in 
those  a  little  older,  the  method  shown  in  Plate  54, 
vertical  extension^  is  the  best.  It  must  not  be 
thought  that  this  can  be  done  only  with  the  auxili- 
aries at  hand  in  a  clinic.  I  have  carried  out  this 
method  of  extension  in  man}^  cases  occurring  in  the 
district  practice  of  my  Munich  policlinic.  Three 
boards,  if  need  be  nailed  to  the  side  of  the  bed,  suffice 
for  the  extension  frame ;  the  rest  is  self-evident.  The 
fear  that  the  fragments  will  unite  with  deformity, 
owing  to  the  great  restlessness  of  the  children  when 
placed  in  this  position,  is  unfounded.  When  the 
weight  balances  that  of  the  leg  and  exerts  moderate 
traction  in  addition,  good  union  is  to  be  expected. 


Explanation  of  Plate    65. 
Fracture  of  the  Patella. 

The  causes  of  unfavorable  union  of  fractures  of  the 
patella  are  manj^.  A  prominent  part  no  doubt  is 
taken  by  the  traction  of  the  quadriceps  which  may 
raise  the  upper  fragment,  while  the  lower  one  is  fast- 
ened to  the  tuberosity  of  the  tibia  by  the  ligamentum 
patellse.  Although  this  is  an  established  fact,  it 
should  not  be  accepted  without  question  as  an  ex- 
planation of  the  displacement  of  the  fragments  or  for 
determining  the  mode  of  treatment  of  these  fractures. 
The  traction  of  the  quadriceps  is  of  importance  only 
when  the  strong  aponeurotic  laj/ers  passing  on 
both  sides  close  to  the  patella  are  likeivise  divided; 
it  has  no  effect  when  the  patella  alone  is  severed. 

The  anatomist  W.  Braune  has  called  attention  to 
these  relations  in  his  beautiful  atlas,  and  has  pointed 
out  the  slight  displacement  in  fractures  of  direct 
origin  (stellar  fractures)  compared  with  the  wide  gap- 
ing in  transverse  fractures  of  the  patella  due  to  mus- 
cular traction. 

Figs.  1  and  2  show^  the  same  preparation  in  identi- 
cal position.  In  Fig.  1  the  patella  alone  is  chiselled 
through ;  in  Fig.  2  the  ligamentous  tense  tissue  ad- 
joining the  patella  on  both  sides  is  likewise  severed. 
In  the  latter  case,  owing  to  the  position  and  a  certain 
traction  of  the  quadriceps,  the  fragments  are  marked- 
ly disjilaced  (dislocatio  ad  longitudineni  cnm  dis- 
ii'dctione)  ;  in  the  former  case  the  gaping  of  the  frag- 
ments is  barely  perceptible. 


64 


Lith. Anst  v.F.Reichhold.Miinchen . 


f:if,.2 


Fragment.    JM: 
supf^rius. 


Fragment. 
jjiferUis. 


\Pate,ll€u 


Fi^.1 


Fizj  h 


Li^h  Anst  V  F  Reichhold.Munchcn 


Explanation  of  Plate   56. 

Fracture  and  Luxation  of  the  Patella. 

Fig.  1. — Old  fracture  of  the  patella^  united  by 
a  broad  ligamentous  mass  (personal  observation). 
We  recognize  the  two  fragments  of  the  patella  and 
the  transverse  depression  between  them,  which  would 
readily  admit  two  or  three  fingers. 

Figs.  2  and  3.— Drawings  from  sketches  made  by 
myself  at  the  College  of  Surgeons,  London.  The 
specimens  bear  the  numbers  536  B  and  536  F.  In 
these  sections  we  observe  the  fragments,  united  in 
Fig.  2  by  a  short  and  broad,  in  Fig.  3  by  a  very  long 
and  thin,  ligamentous  mass.  We  note,  too,  the  car- 
tilaginous investment  of  the  fragments.  At  the  clinic 
I  have  sometimes  encountered  some  hesitation  as  to 
the  condition  of  the  knee-joint  in  fractures  of  the 
patella ;  I  think  these  illustrations  and  those  on  Plate 
55  will  make  it  clear  to  every  one  that  the  knee-joint 
is  always  implicated  in  fracture  of  the  patella,  that 
the  effusion  of  blood  is  within  the  joint  and  often 
enough  must  be  evacuated  by  puncture  with  a  thick 
trocar  so  as  to  permit  an  approximation  of  the  frag- 
ments. It  is  clear  from  the  illustrations  on  Plate  55 
that  in  fracture  of  the  patella  the  dressing  must 
always  be  applied  with  the  knee-joint  straightened, 
i.e.,  with  the  quadriceps  relaxed  as  much  as  possible. 

Fig.  4. — Outward  luxation  of  the  left  patella  in 

a  man  aged  29  (personal  observation,  1880).  This 
luxation  of  the  patella  is  the  most  frequent;  of  course 
a  slight  form  of  it  may  be  often  observed  in  genu  val- 
gum. 


65 


Explanation  of  Plate   57. 

Fractures  In  and  About  the  Knee-Joint.  ' 

Fig.  1. — Normal  course  of  the  epiphyseal  lines 
at  the  lower  end  of  the  femur  and  the  upper  end  of 
the  tibia  and  fibula.  Separation  of  these  epiphyses 
is  not  very  rare  both  on  the  femur  and  on  the  tibia. 
But  the  so-called  inflammator}^  separations  of  the 
epiphyses  in  the  course  of  acute  purulent  osteomj'e- 
litis  may  be  observed  more  frequently  than  those  of 
traumatic  origin.      (Author's  collection.) 

Fig.  2. —  United  stellar  f7Xictiire  of  the  patella. 
Unquestionably  this  was  due  to  direct  injury,  and  yet 
the  fragments  were  not  markedly  displaced.  Compare 
the  explanation  of  Plate  55. 

Fig.  o  a  and  h. — Fracture  by  compression  of  the 
tibia  at  its  upper  end.  We  recognize  the  course  of 
the  lines  of  fracture  at  the  upper  articular  surface  and 
the  difference  in  the  level  of  the  tw^o  halves.  If  the 
young  woman  had  survived,  a  slight  genu  valgum 
would  probably  have  remained  as  a  consequence  of 
this  injury.  The  latter  w^as  caused  by  a  fall  from  a 
loaded  haj^-wagon,  the  woman  undoubtedly  landing 
on  her  feet  in  such  a  way  as  to  cause  a  pressure  of 
the  condyles  of  the  femur  against  the  upper  articular 
surface  of  the  tibia.  The  patient  died  of  acute  sepsis 
starting  from  a  fracture  by  torsion  of  the  same  tibia 
in  its  lower  half,  and  could  not  be  saved  even  by  ex- 
articulation  of  the  leg.  (For  a  more  minute  descrip- 
tion of  this  interesting  case,  see  Langenbeck's  Archiv^ 
Bd.  xli.,  S.  of)?.)  This  variety  of  fracture  by  com- 
pression is  quite  typical ;  it  causes  loosening  (possibly 
lateral  to-and-f  ro  motion)  at  the  knee-joint,  and  is  best 
treated  by  extension  with  weights. 


66 


Fig1 


Fig. 2 


Fig.3' 


U\h .  Anst .  V.  F.  Reichhold ,  Miinchcn . 


VXJvV; 


\ 


f 


Ficj2 


Ftgl 


Lilh  Anst  v.F.Reichhold.Munchcn. 


Explanation  of  Plate   58. 

Fractures    of    the    Leg    Bones  United   with 

Deformity. 

More  attention  is  paid  nowadays  to  the  treatment  of 
fractures  than  was  formerly  the  case.  This  is  due 
to  the  fact  that  physicians  see  more  frequently  than 
before  the  final  results  of  fractures  and  other  injuries 
and  give  an  opinion  as  to  the  capacity  for  work  of 
the  former  patient.  It  is  astonishing  how  often  long- 
continued  disturbances,  even  permanent  restriction  of 
working-power,  are  observed  after  fractures.  The 
physician's  art  in  cases  of  fracture  is  not  limited  to 
effecting  the  patient's  recovery,  but  he  must  bring- 
about  complete  restoration  of  the  function  of  the  mus- 
cles and  joints  implicated,  by  appropriate  measures 
such  as  massage,  passive  movements,  the  use  of 
medico-mechanical  apparatus,  etc. 

Figs.  1  and  2  represent  deformed  legs  which  were 
recently  presented  to  us  for  examination  and  criti- 
cism, as  united  fractures  of  the  leg  bones.  They  are, 
I  should  say,  typical  deformities  after  fractures  which 
must  be  absolutely  avoided.  The  deformity  w^ith 
posterior  deviation  (Fig.  1)  easily  results  during  the 
application  of  a  plaster-of-Paris  dressing  when  trac- 
tion in  the  longitudinal  direction  of  the  leg  is  not 
powerful,  and  this  outward  bending  is  not  prevented 
by  special  lifting  with  slings  or  the  hand  while  the 
plaster  is  hardening. 


67 


Explanation  of  Plate   59. 

Fracture  of  the  Tibia  with  Luxation  of  the 
Capitulum  of  the  Fibula. 

Fig.  1  was  accurately  drawn  from  nature.  The 
patient  was  a  man  (Pommering)  aged  59,  whose  tibia 
was  fractured  by  being  run  over  in  Januar}^,  1894, 
and  he  was  admitted  to  the  clinic  with  a  non-consol- 
idated fracture  (pseudarthrosis)  on  May  29th.  The 
injured  tibia  ivas  at  least  tivo  centimetres  shorter 
than  the  healthy  one,  as  determined  by  repeated  and 
very  careful  mensuration.  Accordingly  it  had  to  be 
assumed  that  the  fibula  of  the  injured  side  must  have 
been  either  likewise  fractured  and  shortened  or  lux- 
ated. The  latter  was  found  to  be  the  case.  The 
fibulae  of  both  sides  were  of  equal  length,  but  the  cap- 
itulum of  that  of  the  injured  side  was  measurably  and 
visibly  dislocated  upward,  luxated.  This  could  not 
be  completely  remedied  even  under  anaesthesia  and 
after  the  fracture  of  the  tibia  had  been  rendered  quite 
movable;  hence  the  fragments  were  nailed  together 
and  are  now  consolidated  in  improved  position. 

Fig.  2  is  exactly  the  same  preparation  as  that  ob- 
served in  Fig.  1  in  the  living  subject:  it  is  r  fracture 
of  the  tibia  in  the  iipjoer  half,  tvith  considerable 
displacement  of  the  fragments  so  as  to  produce 
shortening,  and  tvith  upivard  luxation  of  the  capi- 
tulum of  the  fibida. 

In  the  preparation,  too,  the  form  of  the  upper  frag- 
ment of  the  tibia  is  characteristic;  it  has  been  com- 
pared with  the  mouthpiece  of  a  clarionet  or  a  duck- 
bill. This  fragment  might  become  very  troublesome 
by  its  prominence  and  its  pressure  against  the  thin 
integument  (gangrene).  Many  complicated  measures 
have  been  recommended  (for  instance,  Malgaigne's 
thorn);  the  best  is  a  very  careful  reposition  (possibly 
under  anaesthesia)  and  suitable  dressing  in  extended 
position.     (Personal  observation.) 

03 


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Explanation  of  Plate   60. 

Fractures  of  the  Leg  Bones. 

Fig.  1. — Fracture  of  the  leg  hones  united  ivith 
marked  displace) aent  of  the  fragments.  The  tibia 
and  fibula  are  broken  at  about  the  same  level,  have 
been  similarly  displaced,  and  have  united  by  thick 
callus  formation  which  moreover  joins  tibia  and  fib- 
ula together.  (Pathological  Institute  in  Berlin ;  after 
Wolff,  "Transformation  der  Knochen,"  Plate  VIL, 
Fig.  48.) 

Fig.  ^.—Fracture  of  the  leg  hones  united  ivith 
slight  displacement  of  the  fragments.  The  tibia  is 
fractured  in  its  lower,  the  fibula  in  its  upper  half. 

It  is  quite  correct  that  one  of  the  bones,  if  it  re- 
mains intact,  forms  a  kind  of  splint  for  the  other 
which  is  broken.  It  seems  that  the  location  of  the 
fracture  at  different  levels  of  the  two  bones  likewise 
exerts  a  favorable  influence  by  preventing  marked 
displacement.  The  difference  between  the  displace- 
ments in  Figs.  1  and  2  may  in  part  be  due  to  this  fact, 
i.e.,  to  a  certain  fixation  effected  by  the  interosseus 
membrane.     (Author's  collection.) 

Fig.  3.— Supramalleolar  fracture  of  hotli  leg 
hones  united  ivith  marked  displacement.  The  dis- 
placement is  in  the  sense  of  a  severe  pes  valgus. 
(Author's  collection.) 

Fig.  i.— Recent  fracture  hy  torsion  at  the  loiuer 
end  of  the  tibia.     (Author's  collection.) 


69 


Explanation  of  Plate  61. 
Typical  Malleolar  Fracture. 

This  specimen  is  an  artificially  produced  malleolar 
fracture;  the  leg  was  sawed  through  in  the  frontal 
plane  as  shown,  and  the  preparation  thus  obtained 
was  then  drawn  from  behind.  On  the  foot  we  recog- 
nize at  once  the  great  toe  which  serves  as  a  landmark. 
The  artificial  production  of  this  fracture  in  the  cadaver 
is  not  difficult;  it  succeeds  almost  invariably  when 
the  leg  rests  on  its  outer  side,  the  region  immediately 
above  the  external  malleolus  corresponding  to  the  edge 
of  the  table;  then  a  sudden  strong  pressure  upon  the 
foot  suffices  to  effect  separation  of  the  internal 
malleolus  and  fracture  of  the  fibula  above  the  ex- 
ternal malleolus  in  the  typical  form,  shown  in  the 
illustration.  Every  physician  should  gain  a  correct 
conception,  in  this  manner,  of  this  important  injury; 
it  will  be  more  valuable  to  him  than  all  descriptions. 

In  the  illustration  we  see  the  tibia  in  frontal  longi- 
tudinal section;  the  fibula  was  not  touched  by  the 
saw,  but  the  posterior  portion  of  the  astragalus  and 
the  calcaneus  were  severed.  The  internal  malleolus 
is  separated  and  displaced  downward  and  outward. 
The  most  important  change  is  shown  by  the  fibula  at 
the  point  of  its  fracture— an  angle  open  outward. 
This  is  the  essential  cause  of  the  occurrence  of  trau- 
matic pes  valgus  after  such  fractures.  This  infrac- 
tion of  the  fibula,  the  outward  displacement  of  the 
astragalus  and  of  the  entire  foot,  the  sinking  of  the 
inner  margin  of  the  foot— all  this  can  be  well  seen. 


70 


Lith.  Anst  v.T  Reichhold.Miinchen 


Li»h  Ansl  V  F  Reichhold.Munchen 


Explanation  of  Plate  62. 
Typical  Malleolar  Fracture. 

There  is  no  injury  in  which  the  character  of  a 
fracture  by  traction  is  more  clearly  marked  than  in 
this.  The  fact  is  well  established  that  the  ligaments 
are  often  firmer,  and  better  able  to  resist  a  sudden 
traction,  than  the  bone.  Under  such  circumstances 
portions  of  the  bones  are  torn  off  by  the  respective 
ligaments.  The  present  plate  shows  the  internal 
malleolus  torn  off  by  the  strong  deltoid  ligament  dur- 
ing violent  abduction  of  the  foot.  At  the  junction  of 
the  tibia  and  fibula  we  also  observe  that  small  particles 
are  torn  away  from  the  tibia  in  front  and  behind; 
the  anterior  particle  by  the  anterior  tibio-fibular  liga- 
ment, the  posterior  by  the  posterior  tibio-fibular  liga- 
ment. The  traction  of  the  latter  ligaments,  however, 
was  rendered  possible  only  after  the  malleolus  was 
fractured  by  the  severe  infraction  of  the  external  mal- 
leolus; this  fracture  again  was  effected  by  the  pres- 
sure of  the  foot,  especially  the  astragalus,  against 
the  external  malleolus.  The  separation  of  the  internal 
malleolus,  therefore,  is  the  primary  lesion. 

In  some  cases  only  the  internal  malleolus  is  sepa- 
rated, in  others  the  severest  grade  of  malleolar  frac- 
ture results  as  illustrated  in  the  plate.  The  sepa- 
ration of  particles  of  bone  at  the  fibular  side  of  the 
tibia  is  always  observed,  even  when  the  fibula  is  re- 
markably infracted  and  displaced. 

This  preparation  likewise  was  produced  artificially. 
The  view  into  the  ankle-joint  injured  by  the  malleolar 
fracture  afforded  by  the  drawing  is  particularly  in- 
structive. 


71 


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LiJ^h.Anjt  V  r  Rcichhold.Miincben 


Explanation  of  Plate  64. 

Backward    and    Forward    Luxation   of    the 

Foot. 

The  U\o  preparation  here  shown  were  produced  arti- 
ficiall.y.  Pure  luxations  at  the  ankle-joint  (astragalo- 
crurai  articulation)  are  infrequent  injuries ;  this  is  true 
also  of  luxation  in  the  astragalo-tarsal  joint  (subtalic 
luxation)  and  of  isolated  luxation  of  the  astragalus. 
Combinations  of  fractures  with  luxations  are  here 
relatively  more  frequent. 

Fig.  1. — Backward  luxation  of  the  foot .  "We  ob- 
serve the  astragalus  behind  the  external  malleolus  and 
the  interposed  peroneal  tendons.  The  foot  is  shortened 
in  a  characteristic  way:  a  deep  transverse  furrow 
passes  from  one  malleolus  to  the  other ;  the  heel  por- 
tion of  the  foot  appears  markedly  elongated. 

Fig.  2. — Forivard  luxation  of  the  foot.  The  as- 
tragalus is  situated  in  front  of  the  leg  bones,  both  of 
which  are  visible  in  the  illustration.  The  heel  is  con- 
spicuously shortened,  the  entire  foot  is  enormously 
elongated,  and  the  skin  on  the  dorsum  of  the  foot  is 
stretched. 

The  reduction  of  these  injuries  is  usually  not  diffi- 
cult under  anaesthesia.  Should  obstruction  be  en- 
countered operative  reduction  should  be  performed, 
as  has  recently  been  done  with  success  by  v.  Berg- 
mann  in  a  case  of  isolated  luxation  of  the  astragalus. 


73 


V.  Fractures   and   Luxations   of  the  Lower 

Extremity. 

1.    PELVIS    (PLATE  45). 

Solution  of  continuity  occurs  at  the  pelvis  only  in 
consequence  of  powerful  forces,  such  as  a  fall  from  a 
great  height,  the  impact  of  large  and  heavy  objects, 
the  caving  in  of  an  excavation,  etc.  In  this  way  frac- 
tures and  diastases  of  the  symphyses  between  the  pel- 
vic bones  may  result.  The  latter  are  even  rarer  than 
fractures.  Their  occurrence  at  the  pubic  and  sacro- 
iliac symphyses  necessitates  the  laceration  of  the  ex- 
ceedingly' firm  ligamentous  connections ;  the  diastasis 
of  the  Y-shaped  cartilage  in  the  acetabulum  (compare 
Plate  45,  Fig.  2)  is  possible  only  as  an  incidental  in- 
jury with  other  separations  of  the  bones  constituting 
the  pelvic  ring.  It  is  onlj^  when  such  a  diastasis  is 
complicated  with  pronounced  displacement  of  the  parts 
on  each  other  that  the  diagnosis  can  be  made  with 
certainty.  In  other  cases,  especially  those  in  which 
the  sacro-iliac  symphysis  is  implicated,  merely  the 
signs  of  a  severe  distorsion  are  present,  but  they  suf- 
fice for  making  us  appreciate  the  importance  of  the 
lesion  when  the  cause  of  the  injury  is  known.  The 
treatment  is  based  on  general  principles. 

Pelvic  fractures  should  be  differentiated  clinically 
according  to  whether  isolated  parts  of  the  pelvis  are 
fractured  or  the  continuity  of  the  pelvic  ring  is 

103 


104  FRACTURES   AND   LUXATIONS. 

actually  broken.  In  the  former  case  there  may  be  a 
fracture  of  a  portion  of  the  venter  of  the  ilium,  a  frac- 
ture of  the  sacrum  or  coccyx,  or  of  the  tuberosity  of 
the  ischium.  The  separated  parts  sometimes  appear 
abnormall}"  movable  on  direct  examination,  together 
with  crepitation  and  displacement.  Incidental  in- 
juries are  r^rel}"  present  with  these  separations.  The 
treatment  aims  at  union  in  the  most  correct  position 
possible,  though  moderate  changes  of  form  produce 
no  ill  effect. 

Fractures  of  the  pelvic  ring  are  much  more  impor- 
tant. On  the  one  hand  severe  traumata  must  have 
acted  in  breaking  the  continuity  of  the  pelvic  ring, 
and  on  the  other  hand,  and  partly  in  consequence  of 
this  fact,  incidental  injuries  are  not  rare.  Among 
the  latter  are  lesions  of  the  sciatic  and  other  nerves, 
of  the  femoral  vessels,  of  the  bladder  and  of  the  rec- 
tum, which  are  seldom  observed;  but  relatively  fre- 
quent, and  of  the  greatest  practical  importance,  are 
lesions  of  the  urethra  in  pelvic  fractures  in  men;  they 
manifest  themselves  by  the  escape  of  blood  from  the 
urethra  and  the  admixture  of  blood  in  the  urine. 
The  introduction  of  a  catheter  is  of  importance  not 
only  for  diagnostic  purposes  but  also  therapeutically 
(catheter  a  demeure).  Should  catheterization  fail, 
the  danger  will  be  imminent  of  the  development  of 
an  infiltration  of  urine  in  the  surrouiiding  cellular 
tissue,  with  all  its  evil  results  of  a  fatal  gangrene  and 
sepsis.  Such  cases,  therefore,  require  an  immediate 
free  incision  from  without  in  the  wa}'  of  an  external 
urethrotomy  extending  to  the  cellular  tissue,  which 
is  general!}'  greatlj^  infiltrated  with  blood,  about  the 
urethra  in  the  region  of  the  bulb,  and  especially  the 


THE   LOWER   EXTREMITY.  105 

membranous  part.  The  performance  of  true  urethrot- 
omy is  often  very  difficult  and  sometimes  impossible, 
so  that  the  high  operation  with  the  so-called  retro- 
grade catheterization  would  be  indicated.  Without 
the  auxiliaries  of  a  hospital  this  operation  can  hardly 
be  completed;  but  the  physician  may  be  expected  to 
make  an  incision  extending  into  the  cellular  tis- 
sue about  the  urethra,  and  at  least  to  diagnose  the 
severe  injury,  so  that  appropriate  treatment  may  be 
instituted. 

The  forms  of  fracture  of  the  pelvic  ring  are  very 
manifold.  Aside  from  the  influence  of  the  spinal 
column  and  the  thighs  upon  the  pelvis,  we  meet 
mainly  with  compressions  of  the  pelvis  from  before 
backward  (for  instance,  a  wagon-wheel  passing  over 
a  person  lying  on  the  back,  the  fall  of  a  horse  upon 
its  rider,  etc.),  or  in  a  lateral  direction.  These  rela- 
tions have  also  been  tested  by  experiments.  On  com- 
pression from  before  backward  the  anterior  pelvic 
wall  first  breaks  down  (lines  of  fracture  through  the 
upper  and  lower  surroundings  of  the  obturator  fora- 
men on  both  sides)  and  then  follows  a  separation  of 
the  sacro-iliac  symphysis  or  a  fracture  alongside  of 
it  in  the  sacrum.  On  lateral  compression  a  fracture 
likewise  occurs  first  at  the  anterior  portion  which  pos- 
sesses the  least  resistance  (about  the  symphysis  pubis) 
through  the  obturator  foramen,  then  also  a  fracture 
through  the  ilium  beside  the  sacro-iliac  symphysis, 
unless  the  ligamentous  apparatus  of  the  latter  yields. 
Thus  one  half  of  the  pelvis  may  be  fractured  in  front 
and  behind  simultaneously — the  so-called  double  ver- 
tical fracture  of  Malgaigne.  Numerous  other  lines  of 
fracture   may  arise  when  the  pelvis   is  compressed 


106  FRACTURES   AND    LUXATIONS. 

diagonally.  In  the  living  subject  the  causes  of  pel- 
vic fractures  as  a  rule  are  so  powerful  and  manifold 
that  the  pelvis  does  not  fracture  in  such  a  typical  man- 
ner, but  does  so  at  many  points ;  hence  we  find  speci- 
mens with  fifteen  or  twenty  or  even  more  separate  lines 
of  fracture  and  fissures. 

During  the  examination  it  is  useful  to  attempt  to 
compress  the  pelvis  by  means  of  the  hands  applied 
upon  the  crests  of  the  ilia.  When  fracture  is  present 
this  causes  a  violent  pain  at  its  seat,  sometimes  also 
abnormal  mobility  and  crepitation. 

The  prognosis  depends  upon  the  concomitant  inju- 
ries ;  in  their  absence  union  may  be  exi3ected. 

Treatment. — Suitable  position  (water  bed,  pillows 
of  millet  chaff),  sometimes  on  a  kind  of  portable  frame 
as  in  fractr.re  of  the  vertebrae,  so  as  to  obviate  move- 
ments of  the  patient  for  the  purpose  of  defecation.  A 
belt-shaped  dressing  around  the  pelvis  is  often  useful 
and  especially  grateful  to  the  patient.  In  fracture  in- 
volving the  acetabulum,  careful  mobilization  of  the 
hip- joint. 

2.    IIIP-JOINT. 

Luxations  in  the  hip-joint  are  among  the  rarer  in- 
juries; a  powerful  force  is  required  to  produce  them. 
The  most  important  varieties  are  backward  and  for- 
ward luxations ;  others  are  much  less  common.  Since 
the  investigations  of  Bigelow,  of  Boston,  the  deter- 
mining factor  in  the  mechanism  and  the  fixation  of 
the  luxated  bone  is  the  ileo-femoral  or  Bertini's  liga- 
ment which  is  preserved  in  all  regular  luxations ;  only 
when  it  is  torn  is  an  irregular  dislocation  without 
characteristic  symptoms  possible. 


THE    LOWER   EXTREMITY.  107 

A.  Backward  Luxation.     Luxatio  Postica  s. 
Retrocotyloidea  (Plates  46,  47). 

When  in  the  cadaver  the  thigh  in  f]exed  and  slightly 
adducted  position  is  rotated  inward,  the  joint  capsule 
on  its  posterior  surface  is  tensely  stretched ;  when  the 
motion  is  continued  the  neck  of  the  femur  presses 
against  the  anterior  margin  of  the  acetabulum  which 
forms  the  fulcrum  that  permits  of  the  exertion  of  an 
enormous  force  by  means  of  the  long  lever  (shaft  of 
the  femur)  upon  the  short  lever  (head  of  the  femur). 
The  head  is  crowded  against  the  capsule,  the  latter 
tears  on  its  posterior  surface,  the  head  leaves  its  artic- 
ular connection  (the  ligamentum  teres  being  lacerated) 
and  the  posterior  luxation  is  effected. 

In  the  living  subject  the  backward  dislocation  comes 
about  in  this  manner;  whether  due  to  a  movement  of 
the  thigh  (more  rarely)  or  of  the  trunk  or  pelvis  when 
the  thigh  is  fixed  (more  frequently). 

We  distinguish  an  iliac  and  a  sciatic  luxation. 
In  the  former  the  head  rests  upon  the  ilium;  in  the 
latter  it  is  lower,  on  the  upper  portion  of  the  ischium. 
An  important  anatomical  difference  consists  in  the 
position  of  the  tendon  of  the  obturator  internus  muscle 
with  reference  to  the  head  of  the  femur :  in  iliac  lux- 
ation the  head  of  the  femur  is  above,  in  sciatic  luxa- 
tion below  this  tendon. 

Symptoms. — In  backward  luxations  the  thigh  is 
rotated  inward  and  elastically  fixed  in  more  or  less 
marked  flexion  and  adduction.  When  the  patient  is 
in  dorsal  decubitus  we  recognize  this  position  and  a 
shortening  of  the  limb,  which  is  greater  in  iliac  lux- 
ation and  less  in  sciatic  luxation.     The  shortening 


108  FRACTURES   AND   LUXATIONS. 

may  be  determined  b}^  mensuration,  starting  from  the 
anterior  superior  spine  and  passing  to  a  point  at  the 
knee-joint  (sa}^  the  lower  edge  of  the  patella  or  the  line 
of  the  knee),  both  thighs  being  in  symmetrical  posi- 
tion with  reference  to  the  pelvis.  Roughly,  the  short- 
ening will  be  very  distinct  when  the  two  thighs  are 
placed  in  right-angled  flexion  symmetrically  to  the 
pelvis  and  compared  with  each  other;  the  pelvis  must 
be  quite  horizontal  and  both  anterior  superior  spines 
at  the  same  level.  In  backward  luxation  the  knees 
are  not  at  an  equal  height;  that  of  the  injured  side 
being  considerably  lower  because  the  corresponding 
femur  is  dislocated  backward  on  the  pelvis.  This 
procedure  is  especiall}^  approi)riate  for  examination 
under  anaesthesia. 

The  dislocation  can  also  be  accurately  measured  in 
the  coxal  region.  Under  normal  conditions  the  line 
passing  from  the  anterior  superior  spine  to  the  tuber- 
osity of  the  ischium  across  the  gluteal  region  (for  in- 
stance, by  a  tape),  the  thigh  being  flexed,  strikes  ex- 
actly the  tip  of  the  great  trochanter.  This  is  called 
the  Roser-Nelaton  line.  In  backward  luxation  the 
upper  end  of  the  femur  is  dislocated  upward  and  there- 
fore the  trochanter  is  elevated  above  this  line;  it  is 
found  on  making  this  examination,  the  patient  lying 
on  the  healthy  side,  that  it  is  at  a  greater  or  lesser 
height  above  the  normal,  and  thus  we  can  deduce  the 
position  of  the  head  of  the  femur,  provided  its  con- 
nection with  the  neck  and  shaft  of  the  bone  is  intact. 

During  this  examination  the  inw^ard  rotation  be- 
comes manifest  in  so  far  as  under  normal  conditions, 
in  a  position  midwaj"  between  outward  and  inward 
rotation,  the  tip  of  the  trochanter  is  about  in  the  cen- 


THE    LOWER    EXTREMITY.  109 

tre  of  the  Roser-Nelaton  line.  The  position  of  the 
trochanter  forward  of  tlie  centre  of  this  line  indicates 
the  inward  rotation  of  the  thigh  which  is  never  ab- 
sent in  the  regular  backward  luxations,*  and  thus 
points  to  the  location  of  the  head  of  the  femur  behind 
the  acetabulum. 

This  examination,  too,  will  hardly  be  feasible  as  a 
rule  without  anaesthesia.  The  amount  of  the  displace- 
ment may  also  be  estimated  in  a  more  simple  way  if 
the  patient  is  placed  on  his  back  and  the  physician 
puts  his  thumbs,  in  the  most  symmetrical  position 
possible,  on  the  two  anterior  superior  spines  and 
thence  determines  with  the  index  finger  the  location 
of  the  tip  of  the  trochanter  on  each  side ;  in  this  way 
he  can  sometimes  measure  approximately  the  distance 
of  the  two  bony  points  by  the  number  of  fingers  which 
can  be  inserted  between  them,  and  thus  roughly  es- 
timate the  position  of  the  tip  of  the  trochanter  with 
reference  to  the  pelvis. 

The  presence  of  the  head  of  the  femur  in  its  abnor- 
mal position  is  not  always  demonstrable  under  the 
thick  gluteal  muscles,  particularly  when  the  swelling 
is  great  and  ansesthesia  is  not  induced. 

Active  movements  are  completely  arrested.  Pas- 
sively we  can  effect  a  slight  increase  of  the  perverse 
position  in  the  way  of  adduction  and  inward  rota- 
tion, but  only  by  inflicting  great  pain ;  on  attempt- 
ing abduction  and  outward  rotation  of  the  thigh  we 


*  There  is  a  backward  luxation  with  outward  rotation  of 
the  thigh  ;  this  is  very  rare  and  can  occur  only  when  there  is 
a  laceration  of  at  least  the  outer  crus  of  Bertini's  ligament 
and  the  joint  capsule  is  extensively  torn. 


110  FRACTURES   AND   LUXATIONS. 

find  the  characteristic  elastic  resistance  which  is  due 
mainly  to  the  tension  of  Bertini's  ligament. 

Treatment. — It  has  been  repeatedl}'  stated  that  an- 
sesthesia  cannot  well  be  dispensed  with  in  the  exam- 
ination ;  of  course  when  the  diagnosis  has  been  made 
reduction  immediately  follows.  To  this  end^it  is  de- 
sirable in  all  cases  to  anaesthetize  the  patient  profound- 
ly and  to  place  him  on  the  floor  (upon  a  blanket  or 
mattress).  Then  the  affected  limb  is  raised  until  the 
thigh  is  vertical  and  the  manipulations  are  made  with 
the  leg  bent  at  a  right  angle  in  the  knee-joint.  Some- 
times a  simple  upward  traction  suffices  to  effect  reduc- 
tion, of  course  only  when  the  head  is  close  to  the  pos- 
terior margin  of  the  acetabulum.  If  the  head  is  dis- 
located farther  it  may  on  simple  traction  be  jammed 
against  the  margin  of  the  acetabulum,  and  it  is  readily 
understood  that  in  this  way  the  obstruction  increases 
when  the  thigh  is  at  the  same  time  in  abduction  which 
a  priori  appears  very  useful  for  the  reduction.  Hence 
it  will  be  clear  why  it  is  advised  that  traction  should 
be  made  with  the  thigh  in  adduction,  because  the  head 
glides  more  easily  over  the  margin  of  the  acetabulum 
— that  is  to  say,  traction  in  the  adducted  position 
with  some  inward  rotation.  If  this  fails  traction 
should  also  be  attempted  in  abduction  position  with 
outward  rotation ;  during  this  manipulation,  by  the 
way,  the  head  of  the  femur  may  also  deviate  in  such 
a  manner  that  it  passes  around  the  anterior  surface 
of  the  articulation  (so-called  circumduction).  Since 
such  secondary  movements  of  the  head  of  the  femur, 
therefore,  are  not  excluded,  we  cannot  always  deduce 
the  form  of  laceration  of  the  capsule  from  the  position 
of  the  head.     The  capsule,  which  may  be  lacerated 


THE   LOWER   EXTREMITY.  Ill 

longitudinally  or  transversely,  sometimes  forms  a  true 
obstruction  to  reduction,  which  can  only  be  overcome 
by  operation  (incision) .  By  this  means  I  have  re- 
duced a  backward  luxation  of  several  weeks'  stand- 
ing in  a  child,  with  preservation  of  complete  mobil- 
ity. In  very  old  cases  resection  of  the  hip  may  be 
performed,  or  relinquishing  mobilization  of  the  lux- 
ated liead,  a  subtrochanteric  osteotomy  with  a  view 
to  improve  the  perverse  position. 

B.    FoRVTARD   Luxation.     Luxatio    Antica    s. 
Pr^cotyloidea  (Plates  46,  48): 

Forward  luxations  are  rarer  than  backward;  re- 
ferring to  the  latter,  I  may  be  more  concise  in  my 
remarks. 

The  artificial  production  of  a  forward  luxation  suc- 
ceeds by  outward  rotation  and  abduction.  The  cap- 
sule tears  on  its  anterior  side;  more  superiorly  with  a 
suprapubic  luxation  when  the  thigh  is  extended  at  the 
same  time  (hyperextension) ;  more  inferiorly  with  an 
infrapubic  luxation  when  the  thigh  is  flexed. 

In  the  living  subject  forward  luxation  occurs  in 
the  same  way  or  b}"  a  corresponding  displacement  of 
the  pelvis  when  the  thigh  is  fixed. 

In  all  forw^ard  luxations  the  lower  extremity  is  in 
marked  outward  rotation"^'  and  abduction.  The  de- 
gree of  flexion  varies:  in  suprapubic  luxation  it  is 
slight,  sometimes  even  extension  is  present;  in  infra- 
pubic luxation  flexion  is  never  absent,  and  is  more 

*  Onl}'-  when  the  head  of  the  femur  was  dislocated  upward 
iuto  the  pelvis  has  an  inward  rotation  been  observed  ;  this  is 
extremely  rare. 


112  FRACTURES   AKD   LUXATIONS. 

pronounced  in  proportion  as  the  head  of  the  femur  is 
dislocated  farther  inward  (a  result  of  the  tension  of 
Bertini's  ligament). 

In  suprapubic  luxation  the  head  is  directl}^  palpable 
in  the  inguinal  region ;  it  may  be  either  close  to  the 
margin  of  the  acetabulum  {hixatio  ileo-pectinea  with 
very  slight  abduction)  or  upon  the  os  pubis  (luxatio 
pubica).  The  femoral  artery  is  sometimes  lifted  up 
by  the  head  of  the  femur;  pains  are  present  in  the  re- 
gion of  the  crural  nerve.  At  times  the  patient  can 
still  bear  the  weight  of  his  body  on  the  injured  leg. 

In  the  case  of  an  infrapubic  luxation  there  will  be, 
besides  outward  rotation,  a  more  pronounced  abduc- 
tion and  flexion.  We  distinguished  two  forms:  ob- 
turator luxation  when  the  head  is  in  the  region  of  the 
obturator  foramen,  and  perineal  luxation,  which  is 
very  rare,  when  the  head  is  dislocated  as  far  as  the 
ascending  ramus  of  the  ischium.  In  obturator  lux- 
ation the  head  is  hidden  in  the  depth  and  not  easily 
felt,  the  prominence  of  the  trochanter  is  absent,  and 
the  leg  is  elastically  fixed  in  its  abnormal  position. 

In  the  diagnosis  fracture  of  the  neck  of  the  femur 
is  excluded  by  the  fact  that  though  the  thigh  is  like- 
wise shortened  and  rotated  outward  in  this  injury,  the 
elastic  fixation  characteristic  of  the  luxation  is  ab- 
sent ;  the  thigh  may  be  straightened  without  difficult}^ 
though  it  drops  back  into  outward  rotation ;  and  other 
movements  are  not  prevented  as  in  luxation. 

In  reducing  the  suprapubic  luxation  traction  in 
hj^perextension  may  first  be  necessar}'-  so  as  to  ap- 
proximate the  head  to  the  acetabulum ;  during  this 
step  the  patient  nuist  be  suitably  placed  on  a  table. 
Otherwise  the  same  rule  applies  as  in  backward  lux- 


THE   LOWER   EXTREMITY.  113 

ation,  that  the  patient  must  be  anaesthetized,  placed 
on  the  floor,  and  the  manipulations  made  with  the  leg- 
more  or  less  flexed.  Inward  rotation  followed  by  ad- 
duction generally  succeeds.  Circumduction  of  the 
head  about  the  margin  of  the  acetabulum  (see  above) 
may  be  avoided  by  simultaneous  traction  on  the  thigh. 

C.  Rare  Luxations  at  the  Hip- Joint. 

Downward  luxation  (infracotyloid)  is  very  rare; 
the  head  of  the  femur  is  at  the  lower  margin  of  the 
acetabulum,  the  thigh  is  elongated;  marked  flexion 
is  never  absent  and  slight  abduction  is  usually  pres- 
ent; rotation  is  immaterial.  The  injury  ma}'  result 
from  forced  abduction.  Reduction  b}'  traction  on  the 
flexed  thigh. 

Upward  luxation  (supracotyloid)  is  likewise  very 
rare.  The  head  is  at  the  anterior  inferior  spine  and 
may  be  felt  directly  as  a  spherical  prominence.  The 
thigh  is  extended,  slightly  rotated  outward  and  ad- 
ducted,  and  considerably  shortened.  Reduction  by 
flexion  and  inward  rotation. 

The  name  central  is  applied  to  the  extremely  rare 
luxation  of  the  head  of  the  femur  into  the  pelvis 
through  the  comminuted  acetabulum.  This  observa- 
tion is  of  interest  on  account  of  its  analogy  with  the 
skull  (fracture  of  the  base  of  the  skull  by  the  lower 
maxilla). 

3.   THIGH. 

A.    Fractures    at    the    Upper    End    of    the 
Femur  (Plates  49,  50). 

a.  Fracture  of  the  neck  of  the  femur  is  a  typical  in- 
jury which  is  of  great  practical  importance.     We  dis- 


114  FRACTURES   AND   LUXATIONS. 

tinguish  the  so-called  intracapsular  and  extracapsular 
fractures  of  the  neck  of  the  femur,  according  to  the 
direction  of  the  line  of  fracture,  whether  nearer  to  the 
junction  of  the  head  and  neck  of  the  femur  or  to  the 
trochanter.  As  the  neck  of  the  femur  is  situated 
largely  within  the  joint  capsule,  the  occurrence  of  a 
pure  intracapsular  fracture  is  indeed  possible;  extra- 
capsular fractures,  however,  are  usually  in  part  at 
least  within  the  capsule,  and  therefore  are  "mixed." 

Fractures  of  the  neck  of  the  femur  result  as  a  rule 
from  a  fall  upon  the  hip,  i.e.^  upon  the  trochanter 
(these  are  chiefly  extracapsular  and  complicated  with 
impaction  of  the  neck  into  the  trochanter) ;  they  may 
also  be  due  to  a  fall  upon  the  extended  leg  or  knee 
(often  intracapsular),  and  even  to  tension  and  traction 
of  Bertini's  ligament  during  extensive  rotary  move- 
ments (fracture  by  traction).  It  is  in  the  last-named 
manner,  especially  in  the  cadavers  of  old  subjects,  that 
fractures  of  the  neck  of  the  femur  often  result  when 
the  attempt  is  made  to  produce  an  artificial  luxation 
of  the  hip-joint. 

The  frequent  occurrence  of  these  fractures  in  old 
people  is  due  to  the  fragility  of  the  bones,  which  is 
often  especiall}"  pronounced  at  the  upper  end  of  the 
femur.  Under  normal  conditions,  as  is  well  known, 
this  part  is  very  firm  and  ([uite  equal  to  the  task  of 
bearing  the  weight  of  the  body.  We  are  familiar 
with  the  principles  of  the  architecture  of  the  osseous 
trabeculse,  which  answers  every  mathematical  or 
mechanical  requirement  and  combines  the  highest 
stability  with  the  least  amount  of  bone  substance. 
With  advancing  age  the  osseous  trabecul?e  become 
scantier,  the  interjnediate  cavities  filled  with  fat  grow 


THE    LOWEK    EXTREMITY.  115 

larger,  the  bone  itself  loses  some  organic  ingredients; 
in  this  way  an  osteoporosis  results,  which,  by  the  way, 
occurs  generally^earlier  in  women  than  in  men.  This 
fact  explains  the  more  frequent  occurrence  of  fractures 
of  the  neck  of  the  femur  in  women. 

If  the  pressure  which  produces  the  fracture  acts 
approximately  in  the  longitudinal  direction  of  the 
neck  of  the  femur,  there  is  apt  to  be  an  impaction 
(gomphosis)  of  the  fragments.  In  that  event  the 
thinner  and  firmer  portion  of  the  neck  is  wedged  into 
the  cancellated  structure  of  the  head  (in  intracapsular 
fractures)  or  into  that  of  the  trochanter  (in  extracap- 
sular fractures).  The  impaction  is  of  practical  im- 
portance because  its  symptomatology  is  altered,  and 
because  the  rule  applies  that  it  is  not  to  be  disturbed. 
Clinically,  impacted  fractures  of  this  kind  resemble 
incomplete  fractures  (infractions)  of  the  neck  of  the 
femur;  sometimes  they  merely  present  an  inflexion 
of  one  side  of  the  neck  of  the  femur,  which  produces 
a  change  of  its  direction  and  length,  a  more  or  less 
obtuse-angled  junction  between  neck  and  shaft,  and 
consequentl}"  a  higher  position  of  the  trochanter. 

Si/mjDfoms. — Fracture  of  the  neck  of  the  femur 
should  always  be  suspected  when  a  person  of  ad- 
vanced age  is  unable  to  walk  in  consequence  of  a  fall 
and  the  injured  leg  is  shortened  and  rotated  outward. 
The  differentiation  from  forward  luxation  of  the  femur 
is  made  by  the  fact  that  the  thigh  is  fixed  in  outward 
rotation  but  not  elastically ;  it  can  easily  be  straight- 
ened but  immediateh'  drops  back  outward.  The  out- 
ward rotation  of  the  thigh  is  slighter,  often  quite  in- 
considerable, in  impacted  or  incomplete  fracture; 
very    pronounced   in    the    ordinary   loose    fracture. 


IIG  FRACTURES   AKD   LUXATIONS. 

Otherwise  the  thigh  lies  straight,  without  abduction 
or  adduction  and  without  flexion. 

A  matter  of  great  importance  is  the  higher  position 
of  the  trochanter,  which  is  to  be  demonstrated  in  the 
same  way  as  described  under  posterior  hixation  in  the 
hip-joint.  When  the  thighs  are  in  symmetrical  posi- 
tion to  the  pelvis  the  tape  shows  that  the  distance 
from  the  anterior  superior  spine  to  the  knee  is  often 
considerably  shortened.  The  proof  that  the  tip  of  the 
trochanter  is  situated  above  the  Koser-Nelaton  line  the 
same  distance  that  the  thigh  is  shortened  indicates  that 
the  femur  is  otherwise  intact,  and  that  the  cause  of 
the  shortening  is  to  be  sought  at  the  neck  of  the  femur 
or  in  the  hip-joint.  This  may  be  verified  by  showing 
that  the  distance  from  the  tip  of  the  trochanter  to  the 
knee,  measured  symmetricallj',  is  equal.  The  short- 
ening is  the  result  of  muscular  traction  acting  upon 
the  shaft  of  the  femur  (including  the  trochanter). 

Movements  of  the  injured  thigh  are  possible  in  all 
directions,  though  they  are  painful.  These  move- 
mens  are  associated  with  crepitation  when  the  frag- 
ments are  not  greatly  displaced,  but  are  still  in  con- 
tact. In  rotating  the  extended  thigh  one  landmark  is 
sometimes  very  distinct,  whose  explanation  is  clear  a 
priori ;  namely,  in  extracapsular  fractures  the  shaft 
of  the  femur  turns  about  its  longitudinal  axis;  in  in- 
tracapsular fractures  about  a  radius  whose  length  cor- 
responds to  the  intact  portion  of  the  neck  which  has 
retained  its  connection  with  the  femur. 

Impacted  fractures  are,  as  may  be  gathered  from 
what  has  been  said  above,  distinguished  by  slighter 
shortening  and  less  outward  rotation  of  the  thigh,  by 
the  absence  of  all  crepitation,  by  less  displacement, 


THE    LOWER   EXTREMITY.  117 

and  finally  by  the  fact  that  rotary  movements  at  the 
hip-joint  have  for  a  radius  the  neck  of  the  femur. 

Treatment. — As  the  patients  are  usually  old  people, 
good  nutrition  and  the  preservation  or  improvement 
of  the  general  health  are  of  great  importance.  The 
occurrence  of  an  asthenic  hypostatic  pneumonia  is 
but  too  often  fatal ;  hence  aside  from  suitable  nourish- 
ment frequent  change  of  position  (as  much  as  pos- 
sible), an  occasional  sitting  up,  and  deep  breathing 
are  indicated ;  early  v^alking  about  by  means  of  am- 
bulatory splints  is  especially  useful  in  these  cases. 

Extracapsular  fractures  as  a  rule  unite  by  abundant 
callus;  for  bone  formation  after  fractures  or  osteoto- 
mies in  the  trochanteric  region  in  general  is  usually 
very  extensive.  Intracapsular  fractures  rarely  heal 
b}^  osseous  union  because  the  head  is  poorly  nourished, 
being  normally  connected  only  with  the  ligamentum 
teres;  sometimes  a  ligamentous  union  results,  more 
often  a  true  pseudarthrosis :  the  head  fixed  in  the 
acetabulum  and  the  remnant  of  the  neck  by  its  to- 
and-fro  motion  abrading  each  other  so  that  approxi- 
mately congruent  surfaces  are  in  contact. 

When  the  diagnosis  of  an  impacted  or  incomplete 
fracture  has  been  correctly  made,  the  limb  must  be 
placed  at  rest  and  used  with  caution  until  the  bone  has 
recovered  the  firmness  necessary  to  its  function .  Even 
weeks  after  the  injury  the  impaction  may  be  loosened 
and  the  fragments  become  displaced;  in  these  cases, 
therefore,  great  care  is  required. 

In  the  ordinary  fractures  of  the  neck  of  the  femur 
the  most  exact  possible  reposition  of  the  fragments 
(extension  and  inward  rotation)  is  necessary.  Then 
it  is  best  to  apply  a  correct  adhesive-plaster  extension 


118  FRACTURES   AXD   LUXATI03?^S. 

dressing  with  permanent  extension  by  weights  and 
pulleys  according  to  the  rules  of  surgical  technique; 
the  foot  rests  on  a  Avell-padded  sliding  board  (Volk- 
mann's)  so  as  to  counteract  at  the  same  time  the  out- 
ward rotation  of  the  leg.  As  a  rule  a  weight  of  twelve 
to  fifteen  pounds  suffices  to  keep  the  fragments  in 
good  position.  One  advantage  of  this  dressing  is 
that  it  2^ermits  comparatively  great  mobility  to  the 
patient:  a  semi-recumbent  position  in  the  bed,  even 
some  degree  of  sitting  up,  are  possible  without  harm 
or  pain.  No  other  splint  is  required.  That  plaster- 
of-Paris  and  splint  dressings  may  likewise  be  used  is 
self-evident.  For  these  cases  in  particular  the  new 
ambulatory  splints  (of  Thomas,  Liermann,  and 
Bruns)  are  applicable;  here  the  tuberosity  of  the 
ischium  forms  the  fixed  point,  and  even  permanent 
extension  by  rubber  straps  can  be  employed,  to  be 
changed  at  night  to  traction  by  weights. 

The  attempt  to  fix  the  fragments  b}'  operation  (for 
instance,  the  insertion  of  a  gimlet  from  without)  is 
indicated  only  in  special  cases. 

The  final  result  is  usually  not  very  brilliant.  As 
the  patients  are  old  and  feeble,  w^emust  be  satisfied  if 
they  learn  to  walk  again  after  six  or  eight  weeks,  and 
subsequently  go  about  wuth  the  aid  of  a  cane. 

h.  Isolated  fracture  of  the  great  trochanter  is  a  very 
rare  injury  caused  by  direct  force,  and  is  marked  by 
the  easily  comprehended  displacement  of  the  broken 
prominence  {(Jislocatio  ad  loncjitudinem  cum  dis- 
tract ione).  The  dislocated  fragment  can  be  felt  be- 
hind and  above  through  the  glutrei ;  between  it  and 
the  femur  is  a  wide  diastasis.  The  simplest  treatment 
would  be  the  nailing  of  the  fragment  after  the  com- 


THE   LOWER   EXTREMITY.  119 

pletest  possible  reposition,  which  will  be  facilitated  by 
abduction  of  the  thigh. 

B.  Fractures  of  the  Diaphysis  of  the  Femur 
(Plates  51,  53,  54,  57). 

Fractures  in  the  middle  portion  of  the  diaphysis 
are  frequent,  especially  those  somewhat  above  the 
middle.  After  referring  to  the  plates  enumerated 
above,  a  brief  description  will  suffice  here.  While  a 
portion  of  the  fractures  of  the  diaphysis  result  from 
torsion  (oblique  and  longitudinal  fractures),  <"he  ma- 
jority are  due  to  flexion  by  some  direct  force  (run-over 
accident) . 

These  fractures  are  also  frequent  in  children,  in 
'  whom  they  are  not  seldom  relatively  favorable  by  the 
fact  that  the  thick  periosteum  is  preserved,  whereby 
a  material  displacement  of  the  fragments  is  prevented. 
In  adults  the  displacement  of  the  fragments  is  as  a 
rule  quite  considerable;  the  line  of  fracture  usually 
runs  obliquely,  so  that  a  displacement  easily  results 
from  the  traction  of  the  powerful  muscles,  which  acts 
in  the  main  in  the  longitudinal  direction.  Abnormal 
mobility  is  generall}^  readil}^  demonstrated.  Crepita- 
tion is  usually  quite  distinct,  and  it  must  be  empha- 
sized that  this  symptom  should  be  actually  demon- 
strated; for  if  crepitation  is  absent  the  fragments 
are  presumably  much  displaced  or  soft  parts  are  in- 
terposed ;  crepitation  must  be  elicited  in  order  to  in- 
sure contact  of  the  fractured  surfaces  and  correct 
union.  The  shortening  caused  by  the  longitudinal 
displacement  of  the  fragments  is  alwaj's  readily  deter- 
mined by  mensuration  from  the  knee  (lower  margin 


120  FRACTURES   AND   LUXATIONS. 

of  the  patella  or  the  line  of  the  knee)  to  the  trochanter 
or,  better,  to  the  anterior  superior  spine,  the  thighs 
being  in  symmetrical  position. 

Fractures  above  the  middle  are  as  a  rule  distin- 
guished by  a  typical  displacement,  which  unfortunate- 
ly is  found  but  too  often  after  union,  so  as  to  require 
renewed  surgical  special  interference  on  account  of 
the  angular  position.  A  fracture  of  the  diaphysis  of 
the  femur  above  the  middle  united  with  deformity 
presents  at  the  site  of  the  fracture  an  angular  projec- 
tion outward  and  forward.  In  other  words,  the  upper 
fragment,  under  the  influence  of  the  muscles  inserted 
at  the  great  trochanter,  is  in  a  position  of  flexion  (by 
the  ileo-psoas)  and  abduction  (by  the  glutsei).  The 
lower  fragment  is  ajDproximated  to  the  upper  (over- 
riding) at  the  point  of  fracture,  while  the  lower  j^art 
of  the  shaft  is  still  acted  upon  by  the  adductors.  In 
this  way  the  angular  position  is  produced. 

Treatment. — The  treatment  of  fractures  of  the  dia- 
physis has  become  very  simple  since  the  introduction 
of  the  adhesive-plaster  extension  dressing  with  per- 
manent extension  by  weights.  By  this  means  the 
traction  of  the  muscles  is  successfully  coimteracted 
and  deformities  are  prevented.  But  it  would  be  an 
error  to  suppose  this  treatment  to  be  devoid  of 
trouble;  in  the  first  place  the  dressing  must  be  ap- 
plied with  absolute  correctness,  it  must  cause  no  pres- 
sure anywhere,  must  adhere  by  broad  surfaces,  and  be 
strong  enough  to  bear  a  weight  of  from  twenty  to 
twenty-five  pounds.  For  this  purpose  strips  of  plas- 
ter from  thick  sail-cloth  are  used.  In  order  to  pre- 
vent friction  of  the  leg  upon  the  mattress  a  sliding  foot- 
board (Volkmann's)  is  employed,  which  permits  at 


THE    LOWER    EXTREMITY.  121 

the  same  time  the  retention  of  the  foot  in  a  definite 
position,  if  necessary  in  slight  inward  rotation.  Coun- 
ter-extension is  best  effected  by  raising  the  foot  of  the 
bed  b}^  blocks  of  wood  or  bricks,  and  by  furnishing 
the  healthy  foot  a  firm  point  of  support  by  a  block  of 
wood  placed  in  the  bed. 

After  the  patient  has  been  thus  bedded,  the  next 
task  of  the  surgeon  is  to  keep  in  view  the  point  of  frac- 
ture ;  this  is  facilitated  by  the  fact  that  it  is  open  to 
inspection  at  anytime.  But  the  displacement  cannot 
always  be  clearly  felt  under  the  thick  muscles;  hence 
from  time  to  time  exact  mensuration  of  the  thigh  and 
comparison  with  the  healthy  side  are  required.  The 
measurement  of  the  injured  thigh,  say  from  the  lower 
margin  of  the  patella  (through  the  dressing)  to  the  an- 
terior superior  spine,  is  not  difficult.  The  measure- 
ment of  the  healthy  limb,  however,  must  be  made  in 
precisely  symmetrical  position.  To  this  end  we  first 
determine  the  horizontal  axis  of  the  pelvis,  the  line 
connecting  the  two  anterior  superior  spines;  a  line 
extending  vertically  downward  from  its  centre  (for 
instance,  a  cord  or  tape)  j^ermits  us  to  estimate  the 
degree  of  abduction  of  the  injured  thigh,  which  of 
coarse  remains  undisturbed  in  the  dressing,  and  to 
have  the  healthy  limb  placed  in  equal  abduction  and 
flexion  by  an  assistant.  After  that  mensuration  may 
be  effected  between  the  corresponding  terminal  points 
and  the  results  of  the  two  sides  compared. 

While  this  description  sounds  complicated,  its  per- 
formance is  simple  to  the  experienced,  and  is  im- 
portant for  obtaining  favorable  results. 

Not  rarely  this  examination  proves  that  simple  ex- 
tension, even  with  heavy  weights,  is  insufficient.     In 


122  FRACTURES   AND    LUXATIONS. 

such  severe  cases  the  old  rule  of  bringing  the  lower 
fragment  into  the  same  position  as  that  occupied  by 
the  upper  is  to  be  observed :  the  injured  thigh  is  placed 
in  moderate  abduction  and  flexion  while  extension  by- 
weights  is  applied.  In  children  vertical  extension 
(Plate  5 J:)  is  an  excellent  method.  In  newborn  chil- 
dren and  infants  the  simplest  and  best  mode  of  treat- 
ment is  fixation  of  the  thigh  in  extreme  flexion  against 
the  abdomen  by  means  of  a  wide  strip  of  adhesive 
plaster  passing  from  the  back  over  the  abdomen  with 
the  thigh  bent  upon  it. 

Occasionally  a  plaster-of-Paris  dressing  cannot  be 
dispensed  with  for  the  transportation  of  such  patients ; 
of  late  it  has  found  application  for  the  purpose  of  en- 
abling the  patients  to  walk  early  and  making  the  treat- 
ment ambulatory.  Though  these  and  similar  (splint 
apparatus)  methods  are  valuable,  they  are  not  as  yet 
suitable  for  general  medical  practice. 

When  a  fracture  has  united  with  marked  displace- 
ment it  must  be  again  severed  (osteoclasis  or  osteot- 
omy) and  the  extension  treatment  carried  out  with 
exactness. 

O.  Fractures  at  the  Lower  End  of  the  Femur 
(Plates  52,  53,  Fig.  4;  Plate  57,  Fig.  1). 

These  fractures  are  much  rarer.  Supracondylar 
transverse  fractures  may  present  a  very  pronounced 
displacement,  which  is  effected  in  a  typical  manner 
by  the  influence  of  the  calf  muscles  upon  the  lower 
fragment.  The  latter  is  thus  put  in  flexion,  and  the 
two  fragments  override  (Plate  52).  A  similar  dis- 
placement has  also  been  observed  in  traumatic  sepa- 


THE    LOWER    EXTREMITY.  123 

ration  of  the  epiphysis,  though  as  a  rule  it  is  slighter, 
since  the  periosteal  covering  is  partly  preserved.  Of 
course  the  traction  of  the  thigh  muscles  tends  to  in- 
crease the  displacement. 

The  examination  demonstrates  abnormal  mobility 
at  the  lower  end  of  the  femur,  especially  character- 
istic in  a  transverse  lateral  direction;  with  this  there 
is  creiDitation,  which  has  a  softer  character  in  separa- 
tion of  the  epiphysis.  It  is  advisable  to  make  the 
examination  under  anaesthesia. 

In  the  treatment  permanent  extension  is  suitable, 
perhaps  combined  with  gentle  pressure  (a  w^ound 
roller)  from  behind  against  the  lower  fragment.  At 
the  same  time  it  must  not  be  forgotten  that  the  above- 
named  displacement  of  the  lower  fragment  may"  cause 
very  severe  symptoms  by  pressure  upon  the  large  ves- 
sels or  the  sciatic  nerve. 

Fracture  of  one  condj'le  is  an  intra-articular  injury 
whose  diagnosis  is  made  by  lateral  to-and-fro  move- 
ments at  the  knee,  w^hen  crei^itation  and  local  pain 
may  be  elicited.  As  this  fracture  is  very  apt  to  be 
followed  by  varus  or  valgus  position  at  the  knee-joint, 
careful  treatment  is  necessary,  best  by  an  extension 
dressing.  If  the  eiTusion  of  blood  in  the  knee-joint  is 
profuse  it  should  be  evacuated  by  aspiration. 

4.  KNEE-JOINT. 

A.  Luxations  at  the  Knee-Joixt. 

Injuries  to  the  ligamentous  apparatus  of  the  knee- 
joint  are  not  so  rare  as  true  luxations  of  the  articula- 
tion. What  has  been  more  frequently  observed  of 
late  is  displacement  of  the  semilunar  cartilages,  espe- 


124  FRACTURES   AND   LUXATIONS. 

cially  after  violent  rotary  movements  with  flexed 
knee.  The  external  meniscus  is  more  often  affected 
than  the  internal.  Conditional  for  the  occurrence  of 
these  injuries  is  a  certain  relaxation  of  the  ligaments, 
as  well  as  at  least  a  partial  laceration  of  these  bands. 
If  the  cartilage  is  truly  luxated  the  knee  is  semi-flexed, 
fixed,  and  extension  is  impossible.  Reduction  under 
rotary  movements  after  energetic  distraction  of  the 
joint.  Should  the  firmness  of  the  articulation  be  im- 
paired the  cartilage  is  to  be  fixed  in  its  normal  posi- 
tion by  operation,  i.e.,  by  suture. 

True  luxations  at  the  knee  are  very  rare.  The  leg 
maj^  be — 

Luxated  forward  by  hyperextension  after  laceration 
of  the  lateral  and  crucial  ligaments ; 

Luxated  backward,  i.e..,  this  is  rather  a  forward 
luxation  of  the  condyles  of  the  femur; 

Luxated  laterally,  the  leg  being  placed  in  abduction 
or  adduction. 

In  all  cases  the  condyles  of  the  femur  may  be  pal- 
pated more  or  less  distinctly  in  their  abnormal  posi- 
tion. Owing  to  the  peculiar  force  required  to  pro- 
duce these  luxations,  it  is  inevitable  that  complicated 
injuries  should  be  frequently  present.  Reduction  is 
said  to  be  easy,  by  traction  and  direct  pressure. 

B.  Luxations  of  the  Patella  (Plate  5G). 

Dislocations  of  the  patella  are  not  the  rarest  of  in- 
juries. The  fixation  of  the  patella  is  not  very  strong; 
it  is  like  that  of  a  sesamoid  bone  interposed  between 
the  ligamentum  patellae  and  the  quadriceps  and  only 
loosely  fixed  laterally. 


THE    LOWER   EXTREMITY.  125 

Outward  dislocation  of  the  patella  is  the  most  fre- 
quent form ;  this  is  favored  by  its  position,  since  it  is 
always  situated  more  over  the  external  than  the  in- 
ternal condyle,  especially  so  if  any  valgus  position  is 
present  at  the  knee.  The  luxation  is  incomplete 
when  the  articular  surfaces  are  still  partially  in  con- 
tact; complete,  when  the  patella  is  dislocated  entirely 
to  the  lateral  surface  of  the  external  condyle.  The 
injury  may  arise  when  the  knee  is  extended  and  when 
it  is  flexed;  in  the  former  case  the  patella  passes 
directly  outward  over  the  anterior  surface  of  the  lower 
margin  of  the  femur  (this  may  result  from  muscular 
action  of  the  quadriceps,  the  knee  being  hyperex- 
tended) ;  in  the  latter  case  the  dislocation  occurs  in 
the  groove  between  the  external  condyle  and  the 
tibia,  not  rarely  through  a  force  acting  directly  from 
in  front  inward.  The  diagnosis  of  this  luxation  is 
easy,  since  the  patella  is  absent  from  its  normal  posi- 
tion and  is  felt  in  an  abnormal  location.  Reduction 
by  direct  pressure,  the  knee  being  extended  and  the 
hip  flexed,  thus  relaxing  the  quadriceps. 

A  vertical  luxation  is  present  when  the  patella  is 
rotated  90°  so  that  its  edge  lies  in  the  depression  be- 
tween the  two  condyles  of  the  femur.  We  distin- 
guish an  internal  and  an  external  vertical  luxation, 
according  to  whether  the  cartilaginous  surface  of  the 
patella  is  directed  inward  or  outward.  This  injury 
results  from  a  force  acting  directly  from  in  front  and 
laterally ;  it  is  said  that  it  may  be  due  also  to  pure 
muscular  action.  The  position  of  the  patella  is  easily 
recognized  on  the  extended  leg. 

Complete  inversion  of  the  patella  is  a  rotation  by 
180°,  hence  an  increase  of  the  afore-mentioned  verti- 


126  FRACTURES   AND   LUXATIONS. 

cal  luxation.  Then  the  articular  surface  of  the  pa- 
tella points  forward.  The  injury  is  extremely  rare. 
The  diagnosis  is  difficult  unless  very  exact  palpation 
is  possible  and  the  torsion  of  the  quadriceps  and  of  the 
ligamentum  patellae  can  be  recognized. 

C.  Fractures  of  the  Patella  (Plates  55,  56, 

57). 

Fractures  of  the  patella  are  not  very  frequent,  but 
they  are  of  great  interest.  They  result  from  direct 
and  from  indirect  force,  and  it  is  noteworthy  that  the 
fracture  of  direct  origin  has  usually  a  much  better 
prognosis  than  that  occurring  indirectly.  A  direct 
lesion  of  the  patella  causes  often  a  multiple,  so-called 
stellar  fracture ;  indirect  injury  such  as  occurs  mainly 
through  sudden  muscular  traction  of  the  quadriceps 
(fracture  by  traction) ,  however,  leads  frecjuently  to  a 
transverse  fracture  of  the  patella  with  a  more  or  less 
extensive  laceration  of  the  aponeurotic  layers  passing 
alongside  that  bone.  This  circumstances  in  particular 
is  of  great  importance  (Plate  55),  since  a  marked  gap- 
ing of  the  patellar  fragments  can  result  only  when 
these  lateral  layers  are  torn.  Fracture  by  traction  of 
the  patella  occurs  in  a  pronounced  form  by  sudden 
traction  of  the  quadriceps  in  persons  stumbling,  etc. ; 
under  such  circumstances  the  tendon  of  the  muscle 
and  that  of  the  ligamentum  patellae  resist  the  force; 
in  rare  cases  the  tuberosity  of  the  tibia  is  torn  off, 
more  frequently  the  patella  breaks. 

The  symptoms  are  very  simple  when  the  fracture, 
as  is  usually  the  case,  passes  transversel}' through  the 
middle  of  the  patella  and  is  associated  with  some  gap- 


THE    LOWER    EXTREMITY.  127 

ing  of  the  fragments.  As  the  patella  is  fully  inclosed 
in  the  joint  capsule,  such  injury  is  a  pure  articular 
fracture;  the  effusion  of  blood  is  within  the  joint,  and 
may  exceptionally  be  quite  considerable  and  fill  the 
entire  joint  tensely.  In  recent  cases  it  is  possible  as 
a  rule  to  approximate  the  fragments  so  that  they  touch 
and  produce  distinct  crepitation.  When  only  a  small 
marginal  piece  of  the  patella  is  separated,  and  in  gen- 
eral when  its  periosteum  is  largely  intact,  the  diag- 
nosis may  be  difficult  and  doubtful. 

Treatment. — In  no  other  fracture  is  it  possible  to 
observe  the  fact  common  in  this  injury,  that  cases 
united  with  marked  diastasis  still  functionate  very 
well,  while  cases  in  w^hich  the  fragments  are  well 
placed  present  occasionally  serious  and  permanent  im- 
pairment of  the  function  of  the  limb.  Very  important 
in  this  connection  is  the  condition  of  the  quadriceps. 
This  muscle  presents  in  some  cases  the  S3'mptoms  of 
pronounced  atrophy  due  to  prolonged  inactivity  and 
especially  to  reflex  influences  transmitted  by  the  spinal 
centres.  For  this  reason  a  mode  of  treatment  has  been 
developed  in  recent  times,  which,  while  dispensing 
with  direct  approximation  of  the  fragments,  directs 
its  main  efforts  to  the  care  of  the  quadriceps  by  mas- 
sage (kneading  and  tapotement) ;  this  is  done  every 
day,  and  at  the  same  time  the  fragments  are  moved 
toward  each  other,  the  leg  being  placed  with  knee  ex- 
tended and  hip  flexed,  because  in  this  position  the 
quadriceps  is  relaxed.  Though  this  method  is  cor- 
rect and  valuable,  it  must  still  be  called  rather  one- 
sided, and  there  is  no  reason  why  it  should  not  be  com- 
bined with  an  attempt  to  approximate  the  fragments 
directly. 


128  FRACTURES   AND    LUXATIONS. 

The  unfavorable  results  following  patellar  fractures 
are  unquestionably  due  to  several  causes.  The  trac- 
tion of  the  quadriceps,  with  the  diastasis  of  the  frag- 
ments due  to  it,  is  an  important  factor,  as  is  the 
atrophy  of  this  muscle,  which  in  some  cases,  even 
when  the  lesion  of  the  patella  is  slight,  may  be  ex- 
treme and  perhaps  irreparable.  Of  some  importance, 
too,  is  occasionally  the  effusion  of  blood  present  in  the 
joint,  since  it  crowds  the  fragments  apart.  Unfavor- 
able factors  exist  also  in  the  fragments  themselves, 
e.g.,  the  scanty  bone  formation  dependent  on  the  fact 
that  the  patella  possesses  on  one  side  a  thick  cartilag- 
inous surface,  on  the  other  a  (fibro-peri osteal)  fibrous 
layer.  Then  as  a  rule  there  is  a  kind  of  interposition 
of  the  fibres,  elongated  as  they  are  by  stretching  until 
they  have  given  way,  of  the  external  fibrous  layer, 
which  are  situated  over  the  fractured  surfaces  and 
imprisoned  between  them.  It  is  this  circumstance  in 
particular  which  favors  the  occurrence  of  a  ligamen- 
tous union  even  when  the  fragments  are  in  good 
apposition. 

The  treatment  of  course  must  strive  to  overcome 
these  obstacles  as  much  as  possible.  The  leg  is  to  be 
full}'  extended  at  the  knee  and  bent  at  the  hip  so  as 
to  relax  the  quadriceps.  The  knee-joint  is  fixed  by  a 
posterior  splint,  e.g..,  of  plastic  felt  which  is  moulded 
warm.  The  fragments  are  approximated  manually 
and  freed  by  lateral  friction  as  well  as  may  be  of  the 
interposed  tissues,  and  then  kept  in  position  by  strips 
of  adhesive  plaster  applied  in  the  form  of  slings  and 
crossing  on  the  posterior  surface  over  the  splint.  If 
the  effusion  of  blood  is  great  it  is  removed  by  aspi- 
ration.    The  quadriceps  is  masseed  daily  by  kneading 


THE    LOWER   EXTREMITY.  129 

and  tapotement,  mainly  in  a  downward  direction  so 
as  to  depress  the  upper  fragment. 

A  failure  of  any  kind  of  union  between  the  frag- 
ments and  an  adhesion  of  the  upjjer  fragment  to  the 
anterior  surface  of  the  thigh  are  rare  occurrences, 
both  equally  unfavorable. 

In  severe  cases  operative  interference  cannot  be  dis- 
pensed with.  The  fragments  may  be  united  subcu- 
taneously  by  a  tendon  suture.  Some  prefer  the  use 
of  the  old  clamp  of  Malgaigne.  Direct  bone  suture 
of  the  fragments  of  course  is  the  most  reliable  pro- 
cedure, but  it  should  be  performed  only  by  a  skilled 
surgeon. 

5.  LEG. 

A.  Fracture  of  Both  Bones  in  the  Region  of 
THE  DiAPHYSis  (Plates  58,  60). 

This  injury  is  very  frequent.  It  results  mainly 
from  a  direct  force  (run-over  accidents,  etc.),  and 
affects  both  bones  at  about  the  same  point.  Indirect- 
ly, especially  by  torsion  of  the  body  while  the  foot  is 
fixed,  isolated  oblique  fractures  in  the  lower  part  of 
the  tibia  often  result,  and  the  fibula  then  breaks  only 
in  consequence  of  the  weight  of  the  body  which  it  is 
too  w'eak  to  bear;  the  fracture  then  is  generally  in- 
complete and  frequently  is  higher  up  on  the  shaft.  Of 
course  oblique  fractures  (by  flexion  or  torsion)  are  in 
general  somewhat  more  unfavorable  than  transverse 
fractures,  and  the  fragments  are  more  liable  to  be 
displaced.  Frequently  the  pointed  upper  fragment, 
double-pointed  when  the  line  of  fracture  in  front  ter- 
minates exactly  at  the  crest  of  the  tibia  (in  the  form 


130  FRACTURES   AND   LUXATIONS. 

of  the  mouthpiece  of  a  clarionet),  presses  forward 
against  the  skin  and  may  perforate  it. 

The  diagnosis  of  the  fracture  is  usually  very  easy, 
because  abnormal  mobility,  crepitation,  and  displace- 
ment are  readil}^  demonstrated.  Torsion  of  the  lower 
fragment,  if  present,  will  be  recognized  by  noting  the 
position  of  the  patella  and  of  the  foot,  and  by  careful 
palpation  of  the  crest  of  the  tibia  from  above  and  be- 
low as  far  as  the  point  of  fracture.  To  locate  the 
point  of  fracture  at  the  fibula  sometimes  requires  con- 
siderable skill. 

Treatment. — The  most  exact  reposition  possible 
should  always  be  attempted  by  vigorous  traction  upon 
the  injured  foot,  counter-extension  at  the  thigh  or  pel- 
vis, and  direct  manipulation  at  the  seat  of  the  frac- 
ture. When  the  fracture  is  oblique  the  displacement 
is  very  liable  to  recur.  Protrusion  of  the  upper, 
or  exceptionally  of  the  lower,  fragment  forward 
against  the  thin  skin  is  to  be  met  by  appropriate  posi- 
tion in  slight  hyperextension  at  the  seat  of  the  frac- 
ture. During  the  first  week  the  most  suitable  is  the 
so-called  T-splint  of  Volkmann,  made  of  stout  tin;  of 
course  it  is  to  be  so  well  padded  that  no  injurious  pres- 
sure is  exerted  at  any  point,  particularly  the  region  of 
the  heel. 

In  most  cases  of  this  kind  a  careful  examination 
and  reposition  under  anaesthesia  at  the  end  of  the  first 
week  cannot  be  dispensed  with,  in  my  opinion.  Then 
a  padded  plaster-of -Paris  dressing  is  very  useful ;  a 
second  inspection  must  be  mad^  about  a  week  later. 
Lateral  deviations  are  easilj'  prevented  in  this  way; 
any  rotation  present  requires  even  greater  care.  The 
occurrence  of  a  hyperextension  at  tlie  point  of  fracture 


THE    LOWER    EXTREMITY.  131 

is  to  be  particularly  watched  for,  otherwise  a  recurved 
position  may  remain  behind. 

For  repressing  the  point  of  a  fragment  a  special 
auxiliary  should  be  mentioned,  namely,  Malgaigne's 
screw,  whicli  is  fixed  in  the  dressing  and  made  to 
exert  direct  pressure  on  the  protruding  fragment  by 
means  of  a  movable  stylus.  Good  reposition,  appro- 
priate position,  and  in  some  case  the  application  of 
permanent  extension  by  weights  will  suffice  as  a 
rule. 

After  the  fracture  has  united,  which  process  is 
favored  or  hastened  by  an  ambulatory  dressing,  func- 
tional restoration  should  be  promoted  by  baths,  mas- 
sage, active  and  passive  exercises  of  the  joints. 
Should  a  disturbing  or  painful  bony  prominence  have 
remained  at  the  site  of  the  fracture  it  had  best  be  re- 
moved by  the  chisel ;  the  place  should  be  laid  bare  by 
a  flap  incision. 

B.   Isolated   Fracture  of  the  Tibia   (Plates 

57,  59,  60). 

a.  Fracture  of  the  tibia  at  its  upper  end  (Plate 
57,  Fig.  3)  is  usually  the  result  of  compression,  i.e., 
the  articular  end  of  the  tibia  suffers  an  infraction  by 
the  pressure  of  the  opposite  condyle  of  the  femur. 
This  may  be  due  to  a  fall  upon  the  foot  from  a  con- 
siderable height.  Once  I  observed  this  fracture  as  a 
result  of  springing  from  a  bicycle.  The  symptoms 
presented  are  those  of  a  severe  distorsion  or  contusion 
of  the  joint.  Movements  in  the  joint  are  painful; 
lateral  to-and-fromoA^ements  are  usually  possible,  and 
at  the  upper  end  of  the  tibia  distinct  painful  points 


132  FRACTURES   AND    LUXATIONS. 

are  found.  The  fracture  generally  affects  only  one 
half  of  the  articular  surface,  and  hence  is  very  apt  to 
cause  a  varus  or  valgus  position  in  the  knee-joint. 
After  infraction  of  the  inner  half  of  the  upper  articu- 
lar surface  of  the  tibia  a  varus  position  will  easily  re- 
sult and  remain  behind  unless  specially  prevented. 
Treatment  by  permanent  extension  by  weights  and 
pulleys,  with  a  sliding  foot-board,  perhaps  combined 
with  lateral  traction  by  a  sling  which  over-corrects 
the  threatened  anomalous  position.  Of  course  there 
should  be  early  massage  and  mobilization,  as  in  all 
articular  fractures. 

h.  Traumatic  separation  of  the  epiphysis  at  the 
upper  end  of  the  tibia  is  a  very  rare  inj\uy.  The 
symptoms  present  point  to  the  possibility  of  this  lesion 
in  a  case  of  marked  contusion  at  the  upper  end  of  the 
tibia  in  a  child.  A  positive  diagnosis  is  possible  only 
under  anaesthesia,  when  abnormal  mobility  and  char- 
acteristic cartilaginous  crepitation  can  be  demon- 
strated.    Treatment  on  general  principles. 

c.  Separation  of  the  tuberosity  of  the  tibia,  a  very 
rare  injury  in  children  (in  tlie  form  of  a  separation  of 
an  epiphysis  or  apophysis)  and  in  adults.  The  frag- 
ment is  drawn  upward  by  the  traction  of  the  quadri- 
ceps; active  extension  of  the  leg  in  the  knee-joint  is 
impossible.  The  fragment  is  felt  under  the  skin  and 
is  easil}'  movable  in  all  directions.  The  patella  can 
be  felt  above  to  be  intact.  The  knee-joint  need  not 
necessarily  be  implicated,  but  usually  contains  an 
effusion  of  blood.  The  treatment  may  be  similar  to 
that  of  fractures  of  the  patella;  nailing  the  accu- 
rately replaced  fragment  to  the  tibia  is  the  best 
procedure. 


THE   LOWER   EXTREMITY.  133 


d.  Fracture  of  the  Shaft  of  the  Tibia. 

It  has  been  stated  above  that  in  fracture  of  both  leg 
bones  not  rarely  the  tibia  breaks  first,  fracture  of  the 
fibula  resulting  secondarily.  Aside  from  torsion  this 
may  also  occur  b}^  flexion ;  for  we  may  observe  often 
enough  in  osteoclasis  of  rachitic  leg  bones  that  the 
tibia  alone  breaks,  and  that  additional  force  is  neces- 
sary to  fracture  the  fibula  likewise.  The  symptoms 
as  a  rule  are  clear  and  easily  comprehended.  When 
isolated  fracture  of  the  tibia  is  associated  with  marked 
displacement,  the  fibula,  which  would  serve  as  a  sort 
of  splint,  must  be  implicated.  The  fibula  then  must 
either  be  also  completely  broken  and  present  a  similar 
displacement,  or — and  this  occurs  chiefly  in  fracture 
of  the  tibia  in  the  upper  half  of  the  shaft — it  is  lux- 
ated. Thus  the  capitulum  of  the  fibula  is  found  dis- 
located upward  (Plate  59) .  In  the  more  recent  cases 
this  can  be  overcome  by  careful  reposition ;  for  retain- 
ing the  fragments  a  well-fitting  plaster-of-Paris  dress- 
ing or  permanent  extension  by  weights  is  useful. 

C.  Isolated  Fracture  of  the  Fibula. 

A  very  rare  lesion  which  can  result  only  from  vio- 
lent direct  force.  The  capitulum  of  the  fibula  may  be 
torn  off  by  violent  traction  of  the  biceps  femoris.  Oc- 
casionally the  peroneal  nerve  is  injured.  There  is 
little  tendency  to  displacement.  Treatment  on  gen- 
eral principles. 


134  FRACTURES   AND   LUXATIONS. 


D.   Fractures  at  the    Lower    End    of    Both 

Bones. 

a.  Typical  Fracture  of  the  Ankle  {Plates  61,  62, 

63). 

This  fracture  ma}'  be  compared  to  the  typical  frac- 
ture of  the  epiphysis  of  the  radius;  as  in  the  latter, 
the  mode  of  occurrence,  the  symptoms,  and  the  princi- 
ples of  treatment  have  a  typical  character.  That  in 
fracture  of  the  ankle  the  fibula  breaks  likewise  is 
readily  understood  by  reason  of  the  anatomical  ar- 
rangement, i.e.,  on  account  of  the  firm  union  of  tibia 
and  fibula  at  their  lower  end. 

Typical  malleolar  fracture  results  from  outward 
flexion  of  the  body  when  the  foot  is  fixed  or  from  flex- 
ion of  the  foot  outward.  In  the  latter  wa}^  these 
fractures  may  be  produced  in  the  cadaver:  the  leg  is 
so  placed  as  to  rest  on  the  outer  surface,  the  foot  with 
the  malleolar  region  projecting  over  the  edge  of  the 
table;  a  vigorous  push  brings  the  weight  of  the  ex- 
perimenter's body  to  bear  on  the  foot,  which  assumes 
a  certain  abducted  position,  the  internal  malleolus 
breaks  off,  and,  the  force  continuing  to  act,  the  fibula 
fractures  slightl}^  above  the  external  malleolus,  corre- 
sponding to  the  edge  of  the  table. 

In  the  majority  of  malleolar  fractures  we  find  the 
conditions  exactly  similar.  The  movement  of  abduc- 
tion of  the  foot  in  the  astragalo-crural  joint  causes 
great  tension  of  the  internal  lateral  or  deltoid  liga- 
ment; if  the  movement  continues,  as  a  rule  the  liga- 
ment is  not  lacerated,  but  the  tip  of  the  malleolus  is 
turn  off.     Now  the  force  continuing  acts  on  the  foot 


THE    LOWER    EXTREMITY.  13o 

as  a  whole  and  especially  crowds  the  astragalus  against 
the  external  malleolus  and  produces  the  fracture  above 
the  latter  by  flexion.  In  .^ome  cases,  too,  the  weight 
of  the  body  after  separation  of  the  internal  malleolus, 
the  foot  being  abducted,  produces  fracture  of  the  fibula 
by  flexion,  as  the  latter  bone  alone  is  too  weak  to  bear 
the  weight. 

Symptoms. — In  typical  fracture  of  the  ankle,  there- 
fore, we  find  the  tip  of  the  internal  malleolus  abnor- 
mally movable  and  often  displaced  downward,  while 
the  fibula  is  broken  above  the  external  malleolus.  If 
the  examiner  taken  the  foot  in  his  hand  and  at  the 
same  time  fixes  the  leg  above  the  malleolar  region,  he 
can  produce  an  abnormal  lateral  displacement,  espe- 
cially an  abduction  (pronation)  of  the  foot  to  an  un- 
usual degree.  The  foot,  moreover,  by  itself  occupies 
an  abnormal  position,  a  kind  of  valgus  position,  an 
outward  deviation.  The  region  of  the  internal  malle- 
olus, or  more  correctly  the  fractured  edge  of  the  tibia, 
sometimes  projects  so  markedly  that  the  thin  over- 
lying integument  is  very  tense  and  threatens  to  give 
way;  if  it  is  torn,  z.e.,  if  a  compound  injury  has  re- 
sulted, an  actual  luxation  is  not  rarely  present.  The 
lower  end  of  the  tibia  may  project  through  the  in- 
tegument so  far  that  reposition  can  be  effected  only 
after  extensive  division  of  the  interposed  skin.  On 
the  fibula  the  characteristic  infraction  above  the 
malleolus  is  always  more  or  less  pronounced. 

It  is  very  important  to  picture  to  one's  self  accu- 
rately the  anatomical  details  of  this  fracture.  The 
piece  torn  off  the  internal  malleolus  is  sometimes  very 
small.  The  breaking  off  of  the  fibula  in  the  manner 
described  is  possible,  of  course,  only  by  a  solution  of 


136  FRACTURES   AXD    LUXATIONS. 

the  firm  ligamentous  connection  between  tibia  and 
fibula  at  their  lower  end.  These  ligaments  may  tear ; 
but  a  larger  or  smaller  piece  of  bone  may  be  torn  off 
from  the  articular  end  of  the  tibia  at  the  same  time. 
In  this  way  fragments  are  separated  in  front  by  the 
anterior  tibio-fibular  ligament  and  sometimes  also 
behind  by  the  posterior  ligament  of  the  same  name. 
(See  Plate  02.)  It  is  onh^  after  the  connection  be- 
tween tibia  and  fibula  has  been  severed  that  the  latter 
can  be  bent  sidewise  so  \s  to  produce  a  complete  or 
incomplete  fracture  of  this  bone. 

Prorjuo^hs. — The  t^'pical  malleolar  fracture,  even 
if  not  complicated,  is  always  a  severe  injury.  It  is  a 
true  articular  fracture,  and  doubly  important  for  the 
fact  that  the  affected  joint  has  to  bear  the  weight  of 
the  entire  body.  In  the  treatment,  even  at  the  present 
dav,  serious  mistakes  are  sometimes  committed  which 
jeopardize  the  function  of  the  joint  and  the  working 
capacity  of  the  patient. 

Treatment. — The  first  requirement  is  an  exact  re- 
position of  the  fragments.  The  foot  as  a  whole  must 
be  displaced  toward  the  tibia  in  the  sense  of  an  ad- 
duction. Formerly  stress  was  laid  on  the  fact  that 
the  foot  should  also  be  brought  into  a  true  varus  posi- 
tion so  as  to  overcome  or  prevent  the  present  or  im- 
pending valgus  position.  This  is  not  necessary  if  the 
foot  itself  is  exactly  replaced,  whereby  of  course  the 
angle  of  infraction  at  the  fibula  above  the  external 
malleolus  must  be  completely  effaced.  Sometimes  it 
is  still  more  important  to  counteract  a  backward  dis- 
placement of  the  foot,  which  is  likewise  present,  by 
forward  traction. 

After  reposition,  if  necessary  under  anaesthesia,  the 


THE    LOWER   EXTREMITY.  137 

foot  and  leg  must  be  placed  at  rest,  for  which  purpose 
in  the  first  few  days  a  Volkniann  tin  splint  and  later 
a  Beely's  plaster-of -Paris  splint  are  most  appropriate. 
During  the  first  two  weeks  the  dressing  should  be  re- 
moved every  three  or  four  days,  later  every  other 
day,  with  a  view  of  instituting  massage  of  the  joint 
and  passive  movements ;  during  these  manipulations 
the  position  of  the  foot  should  receive  attention,  for  I 
know  of  cases  in  which  a  good  position  of  the  foot, 
which  was  present  in  the  early  weeks,  became  im- 
paired subsequently  by  reason  of  lack  of  care  in  the 
dressing.  This  point  should  receive  attention  even 
later  on.  After  the  fracture  is  consolidated  and  the 
patient  attempts  to  walk,  the  need  of  a  protective 
splint  is  still  present,  and  he  should  not  be  discharged 
without  a  fitting  shoe  in  order  to  prevent  the  occur- 
rence of  pes  valgus.  Of  late  I  have  observed  good 
results  from  the  application  of  medico-mechanical 
apparatus. 

When  we  have  to  deal  with  an  unfavorable  posi- 
tion of  this  fracture,  and  the  fragments  have  been 
fixed  for  weeks  in  the  objectionable  position,  appro- 
priate operative  treatment  must  be  at  once  resorted 
to.  If  the  new  connections  can  no  longer  be  broken 
by  simple  fracture,  osteotomy  of  the  fibula  at  the  site 
of  the  fracture  and  sometimes  also  of  the  internal 
malleolus  should  be  performed  so  as  to  replace  the 
foot. 

When  the  foot  shows  a  persistent  tendency  to  as- 
sume a  valgus  position,  Dupuytren's  old  splint  dress- 
ing will  still  be  found  useful.  This  consists  in  the 
application  to  the  inner  side  of  the  leg  of  a  splint 
which  is  so  padded  and  fixed  as  to  extend  beyond  the 


138  FRACTURES   AND   LUXATIOKS. 

region  of  the  internal  malleolus  and  the  foot,  so  that 
the  latter  may  be  drawn  b}'  turns  of  a  bandage  toward 
the  splint.  It  is  clear  that  in  this  way  a  powerful 
obstacle  is  opposed  to  an  outward  displacement  and  a 
valgus  position  of  the  foot. 

b.  Other  malleolar  fractures  result  from  adduc- 
tion or  supination  of  the  foot,  whereby  the  tip  of  the 
external  malleolus  is  first  torn  off  and  a  varus  position 
is  apt  to  occur ;  or  else,  from  torsion  of  the  foot  in  the 
astragalo-crural  joint,  whereby  fractures  by  torsion 
and  flexion  of  the  tibia  may  occur,  as  well  as  fracture 
of  the  fibula.  These  injuries  cause  no  great  difficul- 
ties when  the  examination  is  caref  id,  and  should  be 
treated  in  a  manner  similar  to  typical  malleolar  frac- 
ture. The  same  remark  applies  when  only  one  mal- 
leolus is  fractured;  the  acting  force  having  been  less 
intense  or  the  injury  having  resulted  from  indirect 
influences. 

c.  Separation  of  the    Epiphyses  at  the    Lower 

End  of  the  Leg  Bones  {Plate  63). 

This  is  a  rare  injury  which  of  course  occurs  only 
in  children.  Sometimes  it  is  observed  after  forcible 
redressement  of  severe  clubfoot.  It  is  diagnosticated 
by  the  presence  of  abnormal  mobility  above  the  ankle 
region,  together  with  cartilaginous  crepitation.  The 
treatment  requires  rest,  followed  by  exercise. 

d.  Supramalleolar  Fracture  of  Both  Leg  Bones 

{Plate  60,  Fig.  3). 

In  this  fracture,  which  is  not  apt  to  cause  difficulty 
in  the  way  of  diagnosis,  we  find  a  similar  tendency 
to  displacement  as  in   typical  malleolar  fractures. 


THE    LOWER   EXTREMITY.  139 

The  foot  with  the  low^er  fragments  is  very  liable  to 
be  displaced  backward,  which  is  to  be  especially  pre- 
vented. Careful  reposition  and  treatment  on  the 
principles  explained  under  the  head  of  typical  malle- 
olar fractures. 


6.  ANKLE-JOINT. 

It  is  well  knowm  that  the  movements  of  the 'foot  in 
the  way  of  flexion  and  extension  are  effected  in  the 
astragalo-crural  joint;  those  of  pronation  and  supi- 
nation in  the  astragalo-tarsal  joint.  In  the  latter  case 
the  movement  is  of  such  nature  that  the  astragalus 
remains  firmly  connected  with  the  leg  bones;  the 
articulations  involved  being  those  between  the  as- 
tragalus with  the  OS  calcis  and  the  navicular  bone. 
Excessive  movements  cause  distorsion  in  the  joints 
and  eventually  luxations. 

a.     Luxations    in    the    Astragalo- Crural    Joint 

{Plate  64) . 

These  are  the  true  luxations  of  the  foot.  They  may 
be  forward  (by  excessive  dorsal  flexion)  and  back- 
ward (by  excessive  plantar  flexion).  The  position  of 
the  foot  is  so  characteristic  (see  Plate  64)  that  the 
diagnosis  is  made  without  difficulty.  Reduction  is 
effected  by  direct  pressure  upon  the  tibia  forward  or 
backward,  with  simultaneous  flexion  in  the  direction 
which  caused  the  luxation.  Fracture  of  one  malle- 
olus during  this  manipulation  is  of  no  great  conse- 
quence. Lateral  luxations  are  not  possible  without 
malleolar  fractures. 

h.  Luxation  in  the  antragalo-tarsal  joint,  the 


140  FRACTURES   AND   LUXATIONS. 

so-called  luxatio  sub  talc,  may  be  outward  from  ex- 
cessive pronation,  or  inward  from  forced  supination 
of  the  foot.  Much  rarer  are  forward  and  backward 
luxations  in  this  articulation.  The  diagnosis  may  be 
quite  difficult;  exact  palpation  of  the  bony  promi- 
nences, the  demonstration  of  abnormal  mobility'  in  the 
astragalo-crural  joint,  observation  of  the  altered  form 
of  the.  foot,  and  especially  examination  under  anaes- 
thesia will  settle  it.  Reposition  is  difficult;  it  re- 
quires complete  relaxation  of  the  muscles  and  the  use 
of  appropriate  movements  aided  by  direct  pressure. 

c.  Isolated  Luxation  of  the  Astragalus. 

The  astragalus  may  be  dislocated  in  various  direc- 
tions. The  mechanism  is  certainly  a  very  complicated 
one  and  thus  far  not  fully  elucidated.  Marked  de- 
formity is  present ;  the  astragalus  can  be  felt  more  or 
less  distinctly  through  the  soft  parts.  The  tibia  is 
approximated  to  the  sole  of  the  foot  and  sometimes 
articulates  directly  with  the  os  calcis. 

Reduction  is  difficult.  If  it  fails,  it  must  be  forced 
by  means  of  an  incision,  as  in  the  luxations  named 
above.  It  is  a  noteworthy  fact  that  good  results  are 
obtained  by  aseptic  treatment,  although  the  astragalus 
may  have  lost  some  of  its  connections  and  paths  of 
nutrition. 

7.  THE  FOOT. 

A.  Fracture  of  the  Tarsal  Bones. 

a.  Fracture  of  the  Astragalus. 
During  forced  movements  such  as  lead  to  luxation 
at  the  tarsus  we  also  meet  with   infractions,  sepa- 


THE    LOWER    EXTREMITY.  141 

ration  of  fragments,  and  fractures  of  the  astragalus. 
Compression  and  fracture  of  the  astragalus  without 
associated  luxation  sometimes  results  from  a  fall  upon 
the  foot.  The  symptoms  are  those  of  a  severe  distor- 
sion,  and  the  diagnosis  therefore  remains  uncertain. 
Treatment  on  general  principles. 

b.  Fracture  of  the  Calcaneus. 

A  fracture  by  traction  occurs  on  the  tuberosity  of 
the  OS  calcis,  which  may  be  wrenched  off  by  sudden 
action  of  the  calf  muscles.  The  fragment  is  drawn 
up  by  the  muscles.  It  can  be  replaced  when  the  knee 
is  flexed,  and  may  be  fixed  by  nailing. 

Fracture  by  compression  of  the  calcaneus  results 
from  a  fall  upon  the  feet.  The  bone  is  comminuted 
by  the  astragalus,  which,  acting  as  a  wedge,  forces 
the  calcaneus  apart.  The  fragments,  which  are 
usually  numerous,  in  their  displaced  position  cause 
a  widening  of  the  bone  below  the  normal  malleolar 
region.  In  this  way  a  traumatic  flat-foot  may  result, 
which  may  be  slow  to  heal. 

Fracture  of  the  sustentaculum  is  very  rare  and  can- 
not be  positively  diagnosticated ;  it  results  from  forced 
adduction  of  the  foot  and  produces  a  valgus  position, 
with  local  pain. 

c.  Fracture  of  the  Remaining  Bones. 

Fracture  of  the  remaining  tarsal  bones  is  exceed- 
ingly rare;  that  of  the  metatarsals  and  the  phalanges 
is  of  no  practical  importance,  is  generally  easily  diag- 
nosticated, and  its  treatment  is  simple. 


142  FRACTURES   AKD   LUXATIONS. 

B.  Luxations. 
a.  Luxation  of  the  Tarsal  Bones 

is  a  very  rare  injury.  The  diagnosis  is  based  on  the 
palpation  of  the  dislocated  bone.  Reduction  by  direct 
pressure,  if  necessary  through  an  incision. 

h.  Luxation  of  the  Metatarsal  Bones, 

i.e.,  in  Lisfranc's  articulation  so  called,  is  met  with 
mainly  in  the  form  in  which  the  metatarsals  are  dislo- 
cated upon  the  dorsum  of  the  foot.  Reduction  is  diffi- 
cult; each  bone  may  have  to  be  replaced  separately. 

c.  Luxation  of  the  Toes. 

These  injuries  are  analogous  to  those  of  the  fingers, 
and  of  course  are  much  rarer  than  the  latter.  Forced 
dorsal  flexion  causes  an  upward  dislocation  of  the 
phalanges.  The  diagnosis  is  easy,  and  reduction  is 
effected  by  pushing  the  dorsally  flexed  phalanges 
forward. 


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COLUMBIA  UNIVERSITY  LIBRARIES  (hsLstx) 

RD41H36C.1 

Atlas  of  traumatic  fractures  and  luxatio 


2002124785 


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WOOD'S   MEDICAL   HAND   ATLASES. 


L 

Atlas   of  Ophthalmology  and  Oph- 
thalmoscopic Diagnosis. 

By  prof.  dr.  O.  HAAB,  of  Zurich. 
1 02   superbly   colored    figures,   upon    64   plates. 

n. 

Atlas  of  the  Nervous  System  in 
Health  and  Disease, 

By  dr.  CHR.  JAKOB,  of  Erlangen. 

221  figures  on  j?>  plates,  three  of  them  being  fold- 
ing charts. 

IIL 
Atlas  of  Fractures  and  Dislocations. 

By  prof.  HELFERICH,  of  Greifswald. 
166  colored  figures,  upon  64  plates. 

IV. 

Anatomical  Atlas  of  Obstetric  Di= 
agnosis  and  Therapeutics. 

By  DR.  O.  SCHAFFER. 
145    figures    in   color,   upon    56   plates. 

V. 
Atlas  of  Gynaecology. 

By  dr.  O.  SCHAFFER. 
175  figures  in  color,  upon  64  plates. 


These   Atlases   will    be   sold   separately   at   a 
uniform  net  price  of  $3.50  per  volume. 


Mv^^j^^^ 


